UnitedHealthcare® Medicare Advantage Policy Appendix: Applicable Code List Dental Services: Diagnosis Codes

This list of codes applies to the Medicare Advantage Policy Guideline titled Approval Date: December 9, 2020 Dental Services.

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

This list of diagnosis codes is divided into the following sections: Routine Dental Diagnosis Codes that are Not Covered Medical Dental Diagnosis Codes that May Be Covered Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test

Coding Clarification: The following diagnosis codes are considered to be routine dental diagnoses and are not covered.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered K00.0 Anodontia K00.1 Supernumerary teeth K00.2 Abnormalities of size and form of teeth K00.3 Mottled teeth K00.4 Disturbances in tooth formation K00.5 Hereditary disturbances in tooth structure, not elsewhere classified K00.6 Disturbances in tooth eruption K00.7 Teething syndrome K00.8 Other disorders of tooth development K00.9 Disorder of tooth development, unspecified K02.3 Arrested dental caries K02.52 Dental caries on pit and fissure surface penetrating into dentin K02.53 Dental caries on pit and fissure surface penetrating into pulp K02.61 Dental caries on smooth surface limited to enamel K02.62 Dental caries on smooth surface penetrating into dentin K02.63 Dental caries on smooth surface penetrating into pulp K02.7 Dental root caries K02.9 Dental caries, unspecified K03.0 Excessive attrition of teeth

Dental Services: Diagnosis Codes Page 1 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered K03.1 Abrasion of teeth K03.2 Erosion of teeth K03.3 Pathological resorption of teeth K03.4 Hypercementosis K03.5 Ankylosis of teeth K03.6 Deposits [accretions] on teeth K03.7 Posteruptive color changes of dental hard tissues K03.81 Cracked tooth K03.89 Other specified diseases of hard tissues of teeth K03.9 Disease of hard tissues of teeth, unspecified K04.01 Reversible pulpitis K04.02 Irreversible pulpitis K04.1 Necrosis of pulp K04.2 Pulp degeneration K04.3 Abnormal hard tissue formation in pulp K04.4 Acute apical periodontitis of pulpal origin K04.5 Chronic apical periodontitis K04.6 Periapical abscess with sinus K04.7 Periapical abscess without sinus K04.90 Unspecified diseases of pulp and periapical tissues K04.99 Other diseases of pulp and periapical tissues K05.00 Acute gingivitis, plaque induced K05.01 Acute gingivitis, non-plaque induced K05.10 Chronic gingivitis, plaque induced K05.11 Chronic gingivitis, non-plaque induced K05.20 Aggressive periodontitis, unspecified K05.211 Aggressive periodontitis, localized, slight K05.212 Aggressive periodontitis, localized, moderate K05.213 Aggressive periodontitis, localized, severe K05.219 Aggressive periodontitis, localized, unspecified severity K05.221 Aggressive periodontitis, generalized, slight K05.222 Aggressive periodontitis, generalized, moderate K05.223 Aggressive periodontitis, generalized, severe K05.229 Aggressive periodontitis, generalized, unspecified severity K05.30 Chronic periodontitis, unspecified K05.311 Chronic periodontitis, localized, slight K05.312 Chronic periodontitis, localized, moderate K05.313 Chronic periodontitis, localized, severe K05.319 Chronic periodontitis, localized, unspecified severity K05.321 Chronic periodontitis, generalized, slight K05.322 Chronic periodontitis, generalized, moderate

Dental Services: Diagnosis Codes Page 2 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered K05.323 Chronic periodontitis, generalized, severe K05.329 Chronic periodontitis, generalized, unspecified severity K05.4 Periodontosis K05.5 Other periodontal diseases K05.6 Periodontal disease, unspecified K06.010 Localized gingival recession, unspecified K06.011 Localized gingival recession, minimal K06.012 Localized gingival recession, moderate K06.013 Localized gingival recession, severe K06.020 Generalized gingival recession, unspecified K06.021 Generalized gingival recession, minimal K06.022 Generalized gingival recession, moderate K06.023 Generalized gingival recession, severe K06.1 Gingival enlargement K06.2 Gingival and edentulous alveolar ridge lesions associated with trauma K06.3 Horizontal alveolar bone loss K06.8 Other specified disorders of gingiva and edentulous alveolar ridge K06.9 Disorder of gingiva and edentulous alveolar ridge, unspecified K08.0 Exfoliation of teeth due to systemic causes K08.101 Complete loss of teeth, unspecified cause, class I K08.102 Complete loss of teeth, unspecified cause, class II K08.103 Complete loss of teeth, unspecified cause, class III K08.104 Complete loss of teeth, unspecified cause, class IV K08.109 Complete loss of teeth, unspecified cause, unspecified class K08.111 Complete loss of teeth due to trauma, class I K08.112 Complete loss of teeth due to trauma, class II K08.113 Complete loss of teeth due to trauma, class III K08.114 Complete loss of teeth due to trauma, class IV K08.119 Complete loss of teeth due to trauma, unspecified class K08.121 Complete loss of teeth due to periodontal diseases, class I K08.122 Complete loss of teeth due to periodontal diseases, class II K08.123 Complete loss of teeth due to periodontal diseases, class III K08.124 Complete loss of teeth due to periodontal diseases, class IV K08.129 Complete loss of teeth due to periodontal diseases, unspecified class K08.131 Complete loss of teeth due to caries, class I K08.132 Complete loss of teeth due to caries, class II K08.133 Complete loss of teeth due to caries, class III K08.134 Complete loss of teeth due to caries, class IV K08.139 Complete loss of teeth due to caries, unspecified class K08.191 Complete loss of teeth due to other specified cause, class I K08.192 Complete loss of teeth due to other specified cause, class II

Dental Services: Diagnosis Codes Page 3 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered K08.193 Complete loss of teeth due to other specified cause, class III K08.194 Complete loss of teeth due to other specified cause, class IV K08.199 Complete loss of teeth due to other specified cause, unspecified class K08.20 Unspecified atrophy of edentulous alveolar ridge K08.21 Minimal atrophy of the mandible K08.22 Moderate atrophy of the mandible K08.23 Severe atrophy of the mandible K08.24 Minimal atrophy of maxilla K08.25 Moderate atrophy of the maxilla K08.26 Severe atrophy of the maxilla K08.3 Retained dental root K08.401 Partial loss of teeth, unspecified cause, class I K08.402 Partial loss of teeth, unspecified cause, class II K08.403 Partial loss of teeth, unspecified cause, class III K08.404 Partial loss of teeth, unspecified cause, class IV K08.409 Partial loss of teeth, unspecified cause, unspecified class K08.411 Partial loss of teeth due to trauma, class I K08.412 Partial loss of teeth due to trauma, class II K08.413 Partial loss of teeth due to trauma, class III K08.414 Partial loss of teeth due to trauma, class IV K08.419 Partial loss of teeth due to trauma, unspecified class K08.421 Partial loss of teeth due to periodontal diseases, class I K08.422 Partial loss of teeth due to periodontal diseases, class II K08.423 Partial loss of teeth due to periodontal diseases, class III K08.424 Partial loss of teeth due to periodontal diseases, class IV K08.429 Partial loss of teeth due to periodontal diseases, unspecified class K08.431 Partial loss of teeth due to caries, class I K08.432 Partial loss of teeth due to caries, class II K08.433 Partial loss of teeth due to caries, class III K08.434 Partial loss of teeth due to caries, class IV K08.439 Partial loss of teeth due to caries, unspecified class K08.491 Partial loss of teeth due to other specified cause, class I K08.492 Partial loss of teeth due to other specified cause, class II K08.493 Partial loss of teeth due to other specified cause, class III K08.494 Partial loss of teeth due to other specified cause, class IV K08.499 Partial loss of teeth due to other specified cause, unspecified class K08.50 Unsatisfactory restoration of tooth, unspecified K08.51 Open restoration margins of tooth K08.52 Unrepairable overhanging of dental restorative materials K08.530 Fractured dental restorative material without loss of material K08.531 Fractured dental restorative material with loss of material

Dental Services: Diagnosis Codes Page 4 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered K08.539 Fractured dental restorative material, unspecified K08.54 Contour of existing restoration of tooth biologically incompatible with oral health K08.55 Allergy to existing dental restorative material K08.56 Poor aesthetic of existing restoration of tooth K08.59 Other unsatisfactory restoration of tooth K08.81 Primary occlusal trauma K08.82 Secondary occlusal trauma K08.89 Other specified disorders of teeth and supporting structures K08.9 Disorder of teeth and supporting structures, unspecified K09.1 Developmental (nonodontogenic) cysts of oral region M26.20 Unspecified anomaly of dental arch relationship M26.211 Malocclusion, Angle's class I M26.212 Malocclusion, Angle's class II M26.213 Malocclusion, Angle's class III M26.219 Malocclusion, Angle's class, unspecified M26.220 Open anterior occlusal relationship M26.221 Open posterior occlusal relationship M26.23 Excessive horizontal overlap M26.24 Reverse articulation M26.25 Anomalies of interarch distance M26.29 Other anomalies of dental arch relationship M26.30 Unspecified anomaly of tooth position of fully erupted tooth or teeth M26.31 Crowding of fully erupted teeth M26.32 Excessive spacing of fully erupted teeth M26.33 Horizontal displacement of fully erupted tooth or teeth M26.34 Vertical displacement of fully erupted tooth or teeth M26.35 Rotation of fully erupted tooth or teeth M26.36 Insufficient interocclusal distance of fully erupted teeth (ridge) M26.37 Excessive interocclusal distance of fully erupted teeth M26.39 Other anomalies of tooth position of fully erupted tooth or teeth M26.4 Malocclusion, unspecified M26.70 Unspecified alveolar anomaly M26.71 Alveolar maxillary hyperplasia M26.72 Alveolar mandibular hyperplasia M26.73 Alveolar maxillary hypoplasia M26.74 Alveolar mandibular hypoplasia M26.79 Other specified alveolar anomalies M26.81 Anterior soft tissue impingement M26.82 Posterior soft tissue impingement M26.89 Other dentofacial anomalies M26.9 Dentofacial anomaly, unspecified

Dental Services: Diagnosis Codes Page 5 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Routine Dental Diagnosis Codes that are Not Covered M27.3 Alveolitis of jaws M27.61 Osseointegration failure of dental implant M27.62 Post-osseointegration biological failure of dental implant M27.63 Post-osseointegration mechanical failure of dental implant M27.69 Other endosseous dental implant failure

Coding Clarification: The following diagnosis codes are considered to be medical dental diagnoses and may be covered.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered C00.0 Malignant neoplasm of external upper lip C00.1 Malignant neoplasm of external lower lip C00.2 Malignant neoplasm of external lip, unspecified C00.3 Malignant neoplasm of upper lip, inner aspect C00.4 Malignant neoplasm of lower lip, inner aspect C00.6 Malignant neoplasm of commissure of lip, unspecified C00.8 Malignant neoplasm of overlapping sites of lip C00.9 Malignant neoplasm of lip, unspecified C01 Malignant neoplasm of base of tongue C02.0 Malignant neoplasm of dorsal surface of tongue C02.1 Malignant neoplasm of border of tongue C02.2 Malignant neoplasm of ventral surface of tongue C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified C02.4 Malignant neoplasm of lingual tonsil C02.8 Malignant neoplasm of overlapping sites of tongue C02.9 Malignant neoplasm of tongue, unspecified C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum C03.9 Malignant neoplasm of gum, unspecified C04.0 Malignant neoplasm of anterior floor of mouth C04.1 Malignant neoplasm of lateral floor of mouth C04.8 Malignant neoplasm of overlapping sites of floor of mouth C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 Malignant neoplasm of hard palate C05.1 Malignant neoplasm of soft palate C05.2 Malignant neoplasm of uvula C05.8 Malignant neoplasm of overlapping sites of palate C05.9 Malignant neoplasm of palate, unspecified C06.0 Malignant neoplasm of cheek mucosa C06.1 Malignant neoplasm of vestibule of mouth C06.2 Malignant neoplasm of retromolar area

Dental Services: Diagnosis Codes Page 6 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth C06.89 Malignant neoplasm of overlapping sites of other parts of mouth C06.9 Malignant neoplasm of mouth, unspecified C07 Malignant neoplasm of parotid gland C08.0 Malignant neoplasm of submandibular gland C08.1 Malignant neoplasm of sublingual gland C08.9 Malignant neoplasm of major salivary gland, unspecified C09.0 Malignant neoplasm of tonsillar fossa C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior) C09.8 Malignant neoplasm of overlapping sites of tonsil C09.9 Malignant neoplasm of tonsil, unspecified C10.0 Malignant neoplasm of vallecula C10.1 Malignant neoplasm of anterior surface of epiglottis C10.2 Malignant neoplasm of lateral wall of oropharynx C10.3 Malignant neoplasm of posterior wall of oropharynx C10.4 Malignant neoplasm of branchial cleft C10.8 Malignant neoplasm of overlapping sites of oropharynx C10.9 Malignant neoplasm of oropharynx, unspecified C11.0 Malignant neoplasm of superior wall of nasopharynx C11.1 Malignant neoplasm of posterior wall of nasopharynx C11.2 Malignant neoplasm of lateral wall of nasopharynx C11.3 Malignant neoplasm of anterior wall of nasopharynx C11.8 Malignant neoplasm of overlapping sites of nasopharynx C11.9 Malignant neoplasm of nasopharynx, unspecified C12 Malignant neoplasm of pyriform sinus C13.0 Malignant neoplasm of postcricoid region C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect C13.2 Malignant neoplasm of posterior wall of hypopharynx C13.8 Malignant neoplasm of overlapping sites of hypopharynx C13.9 Malignant neoplasm of hypopharynx, unspecified C14.0 Malignant neoplasm of pharynx, unspecified C14.2 Malignant neoplasm of Waldeyer's ring C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx C30.0 Malignant neoplasm of nasal cavity C30.1 Malignant neoplasm of middle ear C31.0 Malignant neoplasm of maxillary sinus C31.1 Malignant neoplasm of ethmoidal sinus C31.2 Malignant neoplasm of frontal sinus C31.3 Malignant neoplasm of sphenoid sinus C31.8 Malignant neoplasm of overlapping sites of accessory sinuses C32.0 Malignant neoplasm of glottis

Dental Services: Diagnosis Codes Page 7 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered C32.1 Malignant neoplasm of supraglottis C32.2 Malignant neoplasm of subglottis C32.3 Malignant neoplasm of laryngeal cartilage C32.8 Malignant neoplasm of overlapping sites of larynx C76.0 Malignant neoplasm of head, face and neck D00.00 Carcinoma in situ of oral cavity, unspecified site D00.01 Carcinoma in situ of labial mucosa and vermilion border D00.02 Carcinoma in situ of buccal mucosa D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge D00.04 Carcinoma in situ of soft palate D00.05 Carcinoma in situ of hard palate D00.06 Carcinoma in situ of floor of mouth D00.07 Carcinoma in situ of tongue D00.08 Carcinoma in situ of pharynx D10.0 Benign neoplasm of lip D10.1 Benign neoplasm of tongue D10.2 Benign neoplasm of floor of mouth D10.30 Benign neoplasm of unspecified part of mouth D10.39 Benign neoplasm of other parts of mouth D10.4 Benign neoplasm of tonsil D10.5 Benign neoplasm of other parts of oropharynx D10.6 Benign neoplasm of nasopharynx D10.7 Benign neoplasm of hypopharynx D10.9 Benign neoplasm of pharynx, unspecified D11.0 Benign neoplasm of parotid gland D11.7 Benign neoplasm of other major salivary glands D11.9 Benign neoplasm of major salivary gland, unspecified D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses D14.1 Benign neoplasm of larynx D16.4 Benign neoplasm of bones of skull and face D16.5 Benign neoplasm of lower jaw bone S02.400A Malar fracture, unspecified side, initial encounter for closed fracture S02.400B Malar fracture, unspecified side, initial encounter for open fracture S02.400D Malar fracture, unspecified side, subsequent encounter for fracture with routine healing S02.400G Malar fracture, unspecified side, subsequent encounter for fracture with delayed healing S02.400K Malar fracture, unspecified side, subsequent encounter for fracture with nonunion S02.400S Malar fracture, unspecified side, sequela S02.401A Maxillary fracture, unspecified side, initial encounter for closed fracture S02.401B Maxillary fracture, unspecified side, initial encounter for open fracture S02.401D Maxillary fracture, unspecified side, subsequent encounter for fracture with routine healing S02.401G Maxillary fracture, unspecified side, subsequent encounter for fracture with delayed healing

Dental Services: Diagnosis Codes Page 8 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered S02.401K Maxillary fracture, unspecified side, subsequent encounter for fracture with nonunion S02.401S Maxillary fracture, unspecified side, sequela S02.402A Zygomatic fracture, unspecified side, initial encounter for closed fracture S02.402B Zygomatic fracture, unspecified side, initial encounter for open fracture S02.402D Zygomatic fracture, unspecified side, subsequent encounter for fracture with routine healing S02.402G Zygomatic fracture, unspecified side, subsequent encounter for fracture with delayed healing S02.402K Zygomatic fracture, unspecified side, subsequent encounter for fracture with nonunion S02.402S Zygomatic fracture, unspecified side, sequela S02.40AA Malar fracture, right side, initial encounter for closed fracture S02.40AB Malar fracture, right side, initial encounter for open fracture S02.40AD Malar fracture, right side, subsequent encounter for fracture with routine healing S02.40AG Malar fracture, right side, subsequent encounter for fracture with delayed healing S02.40AK Malar fracture, right side, subsequent encounter for fracture with nonunion S02.40AS Malar fracture, right side, sequela S02.40BA Malar fracture, left side, initial encounter for closed fracture S02.40BB Malar fracture, left side, initial encounter for open fracture S02.40BD Malar fracture, left side, subsequent encounter for fracture with routine healing S02.40BG Malar fracture, left side, subsequent encounter for fracture with delayed healing S02.40BK Malar fracture, left side, subsequent encounter for fracture with nonunion S02.40BS Malar fracture, left side, sequela S02.40CA Maxillary fracture, right side, initial encounter for closed fracture S02.40CB Maxillary fracture, right side, initial encounter for open fracture S02.40CD Maxillary fracture, right side, subsequent encounter for fracture with routine healing S02.40CG Maxillary fracture, right side, subsequent encounter for fracture with delayed healing S02.40CK Maxillary fracture, right side, subsequent encounter for fracture with nonunion S02.40CS Maxillary fracture, right side, sequela S02.40DA Maxillary fracture, left side, initial encounter for closed fracture S02.40DB Maxillary fracture, left side, initial encounter for open fracture S02.40DD Maxillary fracture, left side, subsequent encounter for fracture with routine healing S02.40DG Maxillary fracture, left side, subsequent encounter for fracture with delayed healing S02.40DK Maxillary fracture, left side, subsequent encounter for fracture with nonunion S02.40DS Maxillary fracture, left side, sequela S02.40EA Zygomatic fracture, right side, initial encounter for closed fracture S02.40EB Zygomatic fracture, right side, initial encounter for open fracture S02.40ED Zygomatic fracture, right side, subsequent encounter for fracture with routine healing S02.40EG Zygomatic fracture, right side, subsequent encounter for fracture with delayed healing S02.40EK Zygomatic fracture, right side, subsequent encounter for fracture with nonunion S02.40ES Zygomatic fracture, right side, sequela S02.40FA Zygomatic fracture, left side, initial encounter for closed fracture S02.40FB Zygomatic fracture, left side, initial encounter for open fracture S02.40FD Zygomatic fracture, left side, subsequent encounter for fracture with routine healing

Dental Services: Diagnosis Codes Page 9 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered S02.40FG Zygomatic fracture, left side, subsequent encounter for fracture with delayed healing S02.40FK Zygomatic fracture, left side, subsequent encounter for fracture with nonunion S02.40FS Zygomatic fracture, left side, sequela S02.411A LeFort I fracture, initial encounter for closed fracture S02.411B LeFort I fracture, initial encounter for open fracture S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing S02.411G LeFort I fracture, subsequent encounter for fracture with delayed healing S02.411K LeFort I fracture, subsequent encounter for fracture with nonunion S02.411S LeFort I fracture, sequela S02.412A LeFort II fracture, initial encounter for closed fracture S02.412B LeFort II fracture, initial encounter for open fracture S02.412D LeFort II fracture, subsequent encounter for fracture with routine healing S02.412G LeFort II fracture, subsequent encounter for fracture with delayed healing S02.412K LeFort II fracture, subsequent encounter for fracture with nonunion S02.412S LeFort II fracture, sequela S02.413A LeFort III fracture, initial encounter for closed fracture S02.413B LeFort III fracture, initial encounter for open fracture S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing S02.413G LeFort III fracture, subsequent encounter for fracture with delayed healing S02.413K LeFort III fracture, subsequent encounter for fracture with nonunion S02.413S LeFort III fracture, sequela S02.42XA Fracture of alveolus of maxilla, initial encounter for closed fracture S02.42XB Fracture of alveolus of maxilla, initial encounter for open fracture S02.42XD Fracture of alveolus of maxilla, subsequent encounter for fracture with routine healing S02.42XG Fracture of alveolus of maxilla, subsequent encounter for fracture with delayed healing S02.42XK Fracture of alveolus of maxilla, subsequent encounter for fracture with nonunion S02.42XS Fracture of alveolus of maxilla, sequela S02.600A Fracture of unspecified part of body of mandible, unspecified side, initial encounter for closed fracture S02.600B Fracture of unspecified part of body of mandible, unspecified side, initial encounter for open fracture S02.600D Fracture of unspecified part of body of mandible, unspecified side, subsequent encounter for fracture with routine healing S02.600G Fracture of unspecified part of body of mandible, unspecified side, subsequent encounter for fracture with delayed healing S02.600K Fracture of unspecified part of body of mandible, unspecified side, subsequent encounter for fracture with nonunion S02.600S Fracture of unspecified part of body of mandible, unspecified side, sequela S02.601A Fracture of unspecified part of body of right mandible, initial encounter for closed fracture S02.601B Fracture of unspecified part of body of right mandible, initial encounter for open fracture S02.601D Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with routine healing S02.601G Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with delayed healing

Dental Services: Diagnosis Codes Page 10 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered S02.601K Fracture of unspecified part of body of right mandible, subsequent encounter for fracture with nonunion S02.601S Fracture of unspecified part of body of right mandible, sequela S02.602A Fracture of unspecified part of body of left mandible, initial encounter for closed fracture S02.602B Fracture of unspecified part of body of left mandible, initial encounter for open fracture S02.602D Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with routine healing S02.602G Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with delayed healing S02.602K Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with nonunion S02.602S Fracture of unspecified part of body of left mandible, sequela S02.609A Fracture of mandible, unspecified, initial encounter for closed fracture S02.609B Fracture of mandible, unspecified, initial encounter for open fracture S02.609D Fracture of mandible, unspecified, subsequent encounter for fracture with routine healing S02.609G Fracture of mandible, unspecified, subsequent encounter for fracture with delayed healing S02.609K Fracture of mandible, unspecified, subsequent encounter for fracture with nonunion S02.609S Fracture of mandible, unspecified, sequela S02.611A Fracture of condylar process of right mandible, initial encounter for closed fracture S02.611B Fracture of condylar process of right mandible, initial encounter for open fracture S02.611D Fracture of condylar process of right mandible, subsequent encounter for fracture with routine healing S02.611G Fracture of condylar process of right mandible, subsequent encounter for fracture with delayed healing S02.611K Fracture of condylar process of right mandible, subsequent encounter for fracture with nonunion S02.611S Fracture of condylar process of right mandible, sequela S02.612A Fracture of condylar process of left mandible, initial encounter for closed fracture S02.612B Fracture of condylar process of left mandible, initial encounter for open fracture S02.612D Fracture of condylar process of left mandible, subsequent encounter for fracture with routine healing S02.612G Fracture of condylar process of left mandible, subsequent encounter for fracture with delayed healing S02.612K Fracture of condylar process of left mandible, subsequent encounter for fracture with nonunion S02.612S Fracture of condylar process of left mandible, sequela S02.621A Fracture of subcondylar process of right mandible, initial encounter for closed fracture S02.621B Fracture of subcondylar process of right mandible, initial encounter for open fracture S02.621D Fracture of subcondylar process of right mandible, subsequent encounter for fracture with routine healing S02.621G Fracture of subcondylar process of right mandible, subsequent encounter for fracture with delayed healing S02.621K Fracture of subcondylar process of right mandible, subsequent encounter for fracture with nonunion S02.621S Fracture of subcondylar process of right mandible, sequela S02.622A Fracture of subcondylar process of left mandible, initial encounter for closed fracture S02.622B Fracture of subcondylar process of left mandible, initial encounter for open fracture S02.622D Fracture of subcondylar process of left mandible, subsequent encounter for fracture with routine healing S02.622G Fracture of subcondylar process of left mandible, subsequent encounter for fracture with delayed healing S02.622K Fracture of subcondylar process of left mandible, subsequent encounter for fracture with nonunion

Dental Services: Diagnosis Codes Page 11 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered S02.622S Fracture of subcondylar process of left mandible, sequela S02.631A Fracture of coronoid process of right mandible, initial encounter for closed fracture S02.631B Fracture of coronoid process of right mandible, initial encounter for open fracture S02.631D Fracture of coronoid process of right mandible, subsequent encounter for fracture with routine healing S02.631G Fracture of coronoid process of right mandible, subsequent encounter for fracture with delayed healing S02.631K Fracture of coronoid process of right mandible, subsequent encounter for fracture with nonunion S02.631S Fracture of coronoid process of right mandible, sequela S02.632A Fracture of coronoid process of left mandible, initial encounter for closed fracture S02.632B Fracture of coronoid process of left mandible, initial encounter for open fracture S02.632D Fracture of coronoid process of left mandible, subsequent encounter for fracture with routine healing S02.632G Fracture of coronoid process of left mandible, subsequent encounter for fracture with delayed healing S02.632K Fracture of coronoid process of left mandible, subsequent encounter for fracture with nonunion S02.632S Fracture of coronoid process of left mandible, sequela S02.641A Fracture of ramus of right mandible, initial encounter for closed fracture S02.641B Fracture of ramus of right mandible, initial encounter for open fracture S02.641D Fracture of ramus of right mandible, subsequent encounter for fracture with routine healing S02.641G Fracture of ramus of right mandible, subsequent encounter for fracture with delayed healing S02.641K Fracture of ramus of right mandible, subsequent encounter for fracture with nonunion S02.641S Fracture of ramus of right mandible, sequela S02.642A Fracture of ramus of left mandible, initial encounter for closed fracture S02.642B Fracture of ramus of left mandible, initial encounter for open fracture S02.642D Fracture of ramus of left mandible, subsequent encounter for fracture with routine healing S02.642G Fracture of ramus of left mandible, subsequent encounter for fracture with delayed healing S02.642K Fracture of ramus of left mandible, subsequent encounter for fracture with nonunion S02.642S Fracture of ramus of left mandible, sequela S02.651A Fracture of angle of right mandible, initial encounter for closed fracture S02.651B Fracture of angle of right mandible, initial encounter for open fracture S02.651D Fracture of angle of right mandible, subsequent encounter for fracture with routine healing S02.651G Fracture of angle of right mandible, subsequent encounter for fracture with delayed healing S02.651K Fracture of angle of right mandible, subsequent encounter for fracture with nonunion S02.651S Fracture of angle of right mandible, sequela S02.652A Fracture of angle of left mandible, initial encounter for closed fracture S02.652B Fracture of angle of left mandible, initial encounter for open fracture S02.652D Fracture of angle of left mandible, subsequent encounter for fracture with routine healing S02.652G Fracture of angle of left mandible, subsequent encounter for fracture with delayed healing S02.652K Fracture of angle of left mandible, subsequent encounter for fracture with nonunion S02.652S Fracture of angle of left mandible, sequela S02.66XA Fracture of symphysis of mandible, initial encounter for closed fracture S02.66XB Fracture of symphysis of mandible, initial encounter for open fracture S02.66XD Fracture of symphysis of mandible, subsequent encounter for fracture with routine healing S02.66XG Fracture of symphysis of mandible, subsequent encounter for fracture with delayed healing

Dental Services: Diagnosis Codes Page 12 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Medical Dental Diagnosis Codes that May Be Covered S02.66XK Fracture of symphysis of mandible, subsequent encounter for fracture with nonunion S02.66XS Fracture of symphysis of mandible, sequela S02.671A Fracture of alveolus of right mandible, initial encounter for closed fracture S02.671B Fracture of alveolus of right mandible, initial encounter for open fracture S02.671D Fracture of alveolus of right mandible, subsequent encounter for fracture with routine healing S02.671G Fracture of alveolus of right mandible, subsequent encounter for fracture with delayed healing S02.671K Fracture of alveolus of right mandible, subsequent encounter for fracture with nonunion S02.671S Fracture of alveolus of right mandible, sequela S02.672A Fracture of alveolus of left mandible, initial encounter for closed fracture S02.672B Fracture of alveolus of left mandible, initial encounter for open fracture S02.672D Fracture of alveolus of left mandible, subsequent encounter for fracture with routine healing S02.672G Fracture of alveolus of left mandible, subsequent encounter for fracture with delayed healing S02.672K Fracture of alveolus of left mandible, subsequent encounter for fracture with nonunion S02.672S Fracture of alveolus of left mandible, sequela S02.69XA Fracture of mandible of other specified site, initial encounter for closed fracture S02.69XB Fracture of mandible of other specified site, initial encounter for open fracture S02.69XD Fracture of mandible of other specified site, subsequent encounter for fracture with routine healing S02.69XG Fracture of mandible of other specified site, subsequent encounter for fracture with delayed healing S02.69XK Fracture of mandible of other specified site, subsequent encounter for fracture with nonunion S02.69XS Fracture of mandible of other specified site, sequela S02.92XB Unspecified fracture of facial bones, initial encounter for open fracture

Coding Clarification: This list contains diagnosis codes that are never covered when given as the primary reason for the test. If a code from this section is given as the reason for the test and you know or have reason to believe the service may not be covered, call UnitedHealthcare to issue an Integrated Denial Notice (IDN) to the member and you. The IDN informs the member of their liability for the non-covered service or item and appeal rights. You must make sure the member has received the IDN prior to rendering or referring for non-covered services or items in order to collect payment.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test R99 Ill-defined and unknown cause of mortality Z00.00 Encounter for general adult medical examination without abnormal findings Z00.01 Encounter for general adult medical examination with abnormal findings Z00.110 Health examination for newborn under 8 days old Z00.111 Health examination for newborn 8 to 28 days old Z00.121 Encounter for routine child health examination with abnormal findings Z00.129 Encounter for routine child health examination without abnormal findings Z00.5 Encounter for examination of potential donor of organ and tissue Z00.70 Encounter for examination for period of delayed growth in childhood without abnormal findings Z00.71 Encounter for examination for period of delayed growth in childhood with abnormal findings Z00.8 Encounter for other general examination Z02.0 Encounter for examination for admission to educational institution Z02.1 Encounter for pre-employment examination

Dental Services: Diagnosis Codes Page 13 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test Z02.2 Encounter for examination for admission to residential institution Z02.3 Encounter for examination for recruitment to armed forces Z02.4 Encounter for examination for driving license Z02.5 Encounter for examination for participation in sport Z02.6 Encounter for examination for insurance purposes Z02.71 Encounter for disability determination Z02.79 Encounter for issue of other medical certificate Z02.81 Encounter for paternity testing Z02.82 Encounter for adoption services Z02.83 Encounter for blood-alcohol and blood-drug test Z02.89 Encounter for other administrative examinations Z02.9 Encounter for administrative examinations, unspecified Z04.6 Encounter for general psychiatric examination, requested by authority Z04.8 Encounter for examination and observation for other specified reasons (Removed 09/30/2018) Z04.81 Encounter for examination and observation of victim following forced sexual exploitation (Effective 10/01/2018) Z04.82 Encounter for examination and observation of victim following forced labor exploitation (Effective 10/01/2018) Z04.89 Encounter for examination and observation for other specified reasons (Effective 10/01/2018) Z04.9 Encounter for examination and observation for unspecified reason Z11.0 Encounter for screening for intestinal infectious diseases Z11.1 Encounter for screening for respiratory tuberculosis Z11.2 Encounter for screening for other bacterial diseases Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z11.51 Encounter for screening for human papillomavirus (HPV) Z11.59 Encounter for screening for other viral diseases Z11.6 Encounter for screening for other protozoal diseases and helminthiases Z11.7 Encounter for testing for latent tuberculosis infection (Effective 10/01/2019) Z11.8 Encounter for screening for other infectious and parasitic diseases Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified Z12.0 Encounter for screening for malignant neoplasm of stomach Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified Z12.13 Encounter for screening for malignant neoplasm of small intestine Z12.2 Encounter for screening for malignant neoplasm of respiratory organs Z12.6 Encounter for screening for malignant neoplasm of bladder Z12.71 Encounter for screening for malignant neoplasm of testis Z12.72 Encounter for screening for malignant neoplasm of vagina Z12.73 Encounter for screening for malignant neoplasm of ovary Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs Z12.81 Encounter for screening for malignant neoplasm of oral cavity

Dental Services: Diagnosis Codes Page 14 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test Z12.82 Encounter for screening for malignant neoplasm of nervous system Z12.83 Encounter for screening for malignant neoplasm of skin Z12.89 Encounter for screening for malignant neoplasm of other sites Z12.9 Encounter for screening for malignant neoplasm, site unspecified Z13.0 Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z13.21 Encounter for screening for nutritional disorder Z13.220 Encounter for screening for lipoid disorders Z13.228 Encounter for screening for other metabolic disorders Z13.29 Encounter for screening for other suspected endocrine disorder Z13.3 Encounter for screening examination for mental health and behavioral disorders (Removed 09/30/2018) Z13.30 Encounter for screening examination for mental health and behavioral disorders, unspecified (Effective 10/01/2018) Z13.31 Encounter for screening for depression (Effective 10/01/2018) Z13.32 Encounter for screening for maternal depression (Effective 10/01/2018) Z13.39 Encounter for screening examination for other mental health and behavioral disorders (Effective 10/01/2018) Z13.4 Encounter for screening for certain developmental disorders in childhood (Removed 09/30/2018) Z13.40 Encounter for screening for unspecified developmental delays (Effective 10/01/2018) Z13.41 Encounter for autism screening (Effective 10/01/2018) Z13.42 Encounter for screening for global developmental delays (milestones) (Effective 10/01/2018) Z13.49 Encounter for screening for other developmental delays (Effective 10/01/2018) Z13.5 Encounter for screening for eye and ear disorders Z13.71 Encounter for non-procreative screening for genetic disease carrier status Z13.79 Encounter for other screening for genetic and chromosomal anomalies Z13.810 Encounter for screening for upper gastrointestinal disorder Z13.811 Encounter for screening for lower gastrointestinal disorder Z13.818 Encounter for screening for other digestive system disorders Z13.820 Encounter for screening for osteoporosis Z13.828 Encounter for screening for other musculoskeletal disorder Z13.83 Encounter for screening for respiratory disorder NEC Z13.84 Encounter for screening for dental disorders Z13.850 Encounter for screening for traumatic brain injury Z13.858 Encounter for screening for other nervous system disorders Z13.88 Encounter for screening for disorder due to exposure to contaminants Z13.89 Encounter for screening for other disorder Z13.9 Encounter for screening, unspecified Z36.0 Encounter for antenatal screening for chromosomal anomalies Z36.1 Encounter for antenatal screening for raised alphafetoprotein level Z36.2 Encounter for other antenatal screening follow-up Z36.3 Encounter for antenatal screening for malformations Z36.4 Encounter for antenatal screening for fetal growth retardation

Dental Services: Diagnosis Codes Page 15 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test Z36.5 Encounter for antenatal screening for isoimmunization Z36.81 Encounter for antenatal screening for hydrops fetalis Z36.82 Encounter for antenatal screening for nuchal translucency Z36.83 Encounter for fetal screening for congenital cardiac abnormalities Z36.84 Encounter for antenatal screening for fetal lung maturity Z36.85 Encounter for antenatal screening for Streptococcus B Z36.86 Encounter for antenatal screening for cervical length Z36.87 Encounter for antenatal screening for uncertain dates Z36.88 Encounter for antenatal screening for fetal macrosomia Z36.89 Encounter for other specified antenatal screening Z36.8A Encounter for antenatal screening for other genetic defects Z36.9 Encounter for antenatal screening, unspecified Z40.00 Encounter for prophylactic removal of unspecified organ Z40.01 Encounter for prophylactic removal of breast Z40.02 Encounter for prophylactic removal of ovary(s) Z40.09 Encounter for prophylactic removal of other organ Z40.8 Encounter for other prophylactic surgery Z40.9 Encounter for prophylactic surgery, unspecified Z41.1 Encounter for cosmetic surgery Z41.2 Encounter for routine and ritual male circumcision Z41.3 Encounter for ear piercing Z41.8 Encounter for other procedures for purposes other than remedying health state Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified Z46.1 Encounter for fitting and adjustment of hearing aid Z56.0 Unemployment, unspecified Z56.2 Threat of job loss Z56.3 Stressful work schedule Z56.4 Discord with boss and workmates Z56.5 Uncongenial work environment Z56.6 Other physical and mental strain related to work Z56.81 Sexual harassment on the job Z56.82 Military deployment status Z56.89 Other problems related to employment Z56.9 Unspecified problems related to employment Z57.0 Occupational exposure to noise Z57.1 Occupational exposure to radiation Z57.2 Occupational exposure to dust Z57.31 Occupational exposure to environmental tobacco smoke Z57.39 Occupational exposure to other air contaminants Z57.4 Occupational exposure to toxic agents in agriculture Z57.5 Occupational exposure to toxic agents in other industries

Dental Services: Diagnosis Codes Page 16 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test Z57.6 Occupational exposure to extreme temperature Z57.7 Occupational exposure to vibration Z57.8 Occupational exposure to other risk factors Z57.9 Occupational exposure to unspecified risk factor Z59.0 Homelessness Z59.1 Inadequate housing Z59.2 Discord with neighbors, lodgers and landlord Z59.3 Problems related to living in residential institution Z59.4 Lack of adequate food and safe drinking water Z59.5 Extreme poverty Z59.6 Low income Z59.7 Insufficient social insurance and welfare support Z59.8 Other problems related to housing and economic circumstances Z59.9 Problem related to housing and economic circumstances, unspecified Z60.2 Problems related to living alone Z62.21 Child in welfare custody Z71.0 Person encountering health services to consult on behalf of another person Z74.1 Need for assistance with personal care Z74.2 Need for assistance at home and no other household member able to render care Z74.3 Need for continuous supervision Z74.8 Other problems related to care provider dependency Z74.9 Problem related to care provider dependency, unspecified Z75.5 Holiday relief care Z76.0 Encounter for issue of repeat prescription Z76.1 Encounter for health supervision and care of foundling Z76.2 Encounter for health supervision and care of other healthy infant and child Z76.3 Healthy person accompanying sick person Z76.4 Other boarder to healthcare facility Z76.81 Expectant parent(s) pre-birth pediatrician visit Z80.1 Family history of malignant neoplasm of trachea, bronchus and lung Z80.2 Family history of malignant neoplasm of other respiratory and intrathoracic organs Z80.49 Family history of malignant neoplasm of other genital organs Z80.51 Family history of malignant neoplasm of kidney Z80.52 Family history of malignant neoplasm of bladder Z80.59 Family history of malignant neoplasm of other urinary tract organ Z80.6 Family history of leukemia Z80.7 Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues Z80.8 Family history of malignant neoplasm of other organs or systems Z80.9 Family history of malignant neoplasm, unspecified Z81.0 Family history of intellectual disabilities Z81.1 Family history of alcohol abuse and dependence

Dental Services: Diagnosis Codes Page 17 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.

Diagnosis Code Description Diagnosis Codes that are Never Covered When Given as the Primary Reason for a Test Z81.2 Family history of tobacco abuse and dependence Z81.3 Family history of other psychoactive substance abuse and dependence Z81.4 Family history of other substance abuse and dependence Z81.8 Family history of other mental and behavioral disorders Z82.0 Family history of epilepsy and other diseases of the nervous system Z82.1 Family history of blindness and visual loss Z82.2 Family history of deafness and hearing loss Z82.3 Family history of stroke Z82.41 Family history of sudden cardiac death Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system Z82.5 Family history of asthma and other chronic lower respiratory diseases Z82.61 Family history of arthritis Z82.62 Family history of osteoporosis Z82.69 Family history of other diseases of the musculoskeletal system and connective tissue Z82.71 Family history of polycystic kidney Z82.79 Family history of other congenital malformations, deformations and chromosomal abnormalities Z82.8 Family history of other disabilities and chronic diseases leading to disablement, not elsewhere classified Z83.0 Family history of human immunodeficiency virus [HIV] disease Z83.1 Family history of other infectious and parasitic diseases Z83.2 Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z83.3 Family history of diabetes mellitus Z83.41 Family history of multiple endocrine neoplasia [MEN] syndrome Z83.49 Family history of other endocrine, nutritional and metabolic diseases Z83.511 Family history of glaucoma Z83.518 Family history of other specified eye disorder Z83.52 Family history of ear disorders Z83.6 Family history of other diseases of the respiratory system Z83.71 Family history of colonic polyps Z83.79 Family history of other diseases of the digestive system Z84.0 Family history of diseases of the skin and subcutaneous tissue Z84.1 Family history of disorders of kidney and ureter Z84.2 Family history of other diseases of the genitourinary system Z84.3 Family history of consanguinity Z84.81 Family history of carrier of genetic disease Z84.89 Family history of other specified conditions

Dental Services: Diagnosis Codes Page 18 of 18 UnitedHealthcare Medicare Advantage Policy Appendix: Applicable Code List Approval 12/09/2020 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc.