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UTILIZATIONUTILIZATION REVIEW REVIEW GUIDELINES GUIDELINES

Approved by:

Approved by: A. Thomas Correia, DDS 1/1/21 Dental Director

Delta Dental Utilization Review Guidelines Page 1 1/1/21 BENEFIT GUIDELINES

The following sections list the appropriate CDT (Codes for Dental Terminology) codes, a description of the procedure, a short summary of the benefit guideline and the documentation requirements for that procedure code. Although a procedure code may be listed in our benefit guidelines, a subscriber's contract may not cover all procedures. The group/subscriber account chooses the benefit coverage.

TABLE OF CONTENTS

PREFACE Definition of Terms Application of Time Limitations BENEFIT GUIDELINES Code on Dental Procedures DIAGNOSTIC D0100 - D0999 PREVENTIVE D1000 - D1999 RESTORATIVE D2000 - D2999 D3000 - D3999 PERIODONTICS D4000 - D4999 , REMOVABLE D5000 - D5899 MAXILLOFACIAL PROSTHETICS D5900 - D5999 IMPLANT SERVICES D6000 - D6199 PROSTHODONTCS, FIXED D6200 - D6999 ORAL AND MAXILLOFACIAL SURGERY D7000 - D7999 D8000 - D8999 ADJUNCTIVE GENERAL SERVICES D9000 - D9999 EVIDENCE-BASED PREFACE The following dental treatment guidelines should be used in determining whether a service qualifies for coverage under the terms of a subscriber's contract. While services may be dentally appropriate and necessary, they may not be covered due to contractual limitations. In administering the policies, the following definitions should be used consistently. APPROVE- The procedure has been reviewed and qualifies for coverage in accordance with the guidelines set forth in this document. The procedure is subject to all deductibles, co-insurance and maximums under the subscriber's contract. DENY- The procedure has been reviewed and does not qualify for benefits under the guidelines set forth in this document. A procedure may also be denied for contractual reasons. Whenever a procedure is denied, the patient is held responsible up to the dentist's charge. NOT BILLABLE TO THE PATIENT - No payment is made by DDRI and the patient is held harmless. This only applies to a participating dentist (local or DeltaUSA). Example: Unbundling. Dentist submits for a (D3220) and (D3310-D3330) on the same within 60 days of each other. The pulpotomy is considered part of the root canal and it will not be paid separately. No payment is made and the fee is not billable to the patient by a participating dentist/DENY- non-participating dentist.

Delta Dental Utilization Review Guidelines Page 2 1/1/21 ALTERNATE BENEFIT- A non covered procedure is performed, yet the subscriber's contract covers a least costly alternative procedure, an alternate benefit is applied. The patient is held responsible for the difference up to the dentist's charge. Example: Composite restorations on posterior teeth. An alternate benefit of an restoration will be made and the patient is responsible for the difference up to the dentist's charge for the composite restoration. SUBMITTED AMOUNT- The dentist's charge for the service. APPROVED AMOUNT- For a participating dentist: the fee profile. For non-participating dentist: the submitted charge. If a patient with a PPO plan sees a dentist who is non-participating PPO but participating Premier, the approved amount will be the dentist's Premier allowance. ALLOWED AMOUNT- For a participating dentist: the fee profile. For a non-participating dentist, the allowance is equal to the fee set in the Ingenix (Usual and Customary) table. POLICY REGARDING APPLICATION OF TIME LIMITATIONS Time limitations apply when claims history reflects that a procedure has been performed or uploaded from another carrier. BENEFIT GUIDELINES The following sections list the appropriate CDT (Codes for Dental Terminology) codes, a description of the procedure, a short summary of the benefit guideline and the documentation requirements for that procedure code. Although a procedure code may be listed in our benefit guidelines, a subscriber's contract may not cover all procedures.

Payment for a procedure code is based on Delta Dental's reimbursement policies, utilization review guidelines, and documentation requirements, which may include descriptions that are at variance with descriptions included in CDT codes (Code for Dental Terminology), which are owned and licensed by the American Dental Association. CLASSIFICATION OF MATERIALS Classification of Metals (Source: ADA Council on Scientific Affairs) The noble metal classification system has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of metal content: high noble alloys - noble metal content >= 60% (+platinum group) and gold >= 40%; and metals of the platinum group are platinum, palladium, rhodium, iridium, osmium and ruthenium. Porcelain/ceramic - Refers to pressed, fired, polished or milled materials containing predominantly inorganic refractory compounds including porcelains, glasses, ceramics and glass- ceramics. Resin - Refers to any resin-based composite, including fiber or ceramic reinforced polymer compounds, and glass ionomers.

Procedures that require review by DCM/Consultant, are denoted in Documentation Requirements

DIAGNOSTIC 0100-0999 Code Description Administrative Guidelines Documentation of Service Requirements CLINICAL ORAL EVALUATIONS The codes in this section recognize the cognitive skills necessary for patient evaluation. The collection and recording of some data and components of the dental examination may be delegated; however, the evaluation, which includes diagnosis and treatment planning, is the responsibility of the dentist. As with all ADA procedure codes, there is no distinction made between the evaluations provided by general practitioners and specialists. Report additional diagnostic and/or definitive procedures separately. Evaluations/examinations include, but are not limited to, examination of all hard and soft tissues of the oral cavity, periodontal charting, and screening. Evaluations/examinations must be performed by a licensed dentist to be considered for reimbursement. The term specialized procedure describes a dental service or procedure that is used when unusual or extraordinary circumstances exist and is not generally used when conventional methods are adequate. General Policy - Clinical oral evaluations time limitations are established by group/individual contract.

Delta Dental Utilization Review Guidelines Page 3 1/1/21 General Policy - Infection control is included in the fee for the dental services provided. Separate fees are not billable to the patient by a participating dentist. Rationale: Infection control is considered a component of all dental procedures performed.

The following services are covered with teledentistry:

Teledentistry codes D9995 or D9996 must be submitted with procedure codes D0120, D0140, D0170 and D0171 when conducted as a teledentistry visit to ensure timely payment. Code DO150 (Comprehensive oral evaluation - new or established patient) when submitted as a teledentistry visit will be changed to an alternate benefit of D0140 and will be paid subject to normal limitations/frequencies. Benefit plan deductibles, copayments, and time and frequency limitations will apply equally to teledentistry and in- person exams as of August 3, 2020. Time and frequency limitations also apply to exams performed prior to March 18, 2020. (Note: Members who had teledentistry exams between March 18 and August 2, 2020 are not subject to time and frequency limitations, in accordance with our Emergency Teledentistry Policy). To qualify as a teledentistry exam, the exam must be conducted by telephone or other telecommunications system with the dentist using videos, photographs, x-rays or other diagnostic tools for diagnosis and treatment recommendations. Teledentistry is not a service, but a means by which to deliver a service when the patient is in one location and the dentist is in another. The means by which teledentistry services are delivered must be in accordance with applicable

information. The treatment of patients who receive an exam by teledentistry must be properly documented in the

service will be treated as an exam and charged as such should be communicated to the patient and documented.

Documentation Requirements: D0120 Periodic oral evaluation: The following documentation is required: o Intra-oral photos of any suspicious soft/hard tissues and problem areas or teeth o Review of new or existing x-rays o Clinical treatment notes should support findings D0140 Limited oral evaluation - problem focused: Clinical treatment notes must detail the conversation with the patient and include, but are not limited to:

o Specific area/or tooth or problem initiating the phone call o Symptoms: pain, swelling, cold/hot/biting sensitivity o Problem timeline: when started o Symptom progression, i.e.: Same, worse, better o Treatment rendered: prescriptions/referrals/verbal patient instructions The exam will only qualify as a teledentistry exam if the following is documented in the clinical treatment notes: o A review of existing treatment notes, x-rays and Intra-oral photos and/or o A review of the images the patient provided via cell phone, photos, etc. These should be uploaded into the patient record.

Same documentation as D0140.

Same documentation as D0140.

Delta Dental Utilization Review Guidelines Page 4 1/1/21 D0120 Periodic oral CDT: An evaluation performed on a patient of record to determine any changes in the patient's dental and medical evaluation health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Up to two periodic oral exams may be benefited based on the subscriber's contract, per member, per calendar year or policy year (beginning with the year following the initial exam) when performed by a general dentist. Additional periodic exams are not covered unless specified in the subscriber's contract. However, patients with double Delta Dental of Rhode Island coverage are allowed an additional exam per calendar year.

D0140 Limited oral CDT: An evaluation limited to a specific oral health problem or complaint. This may require interpretation of information evaluation - problem acquired through additional diagnostic procedures. Report additional diagnostic procedures separately. Definitive focused procedures may be required on the same date as the evaluation.

Typically, patients receiving this type of evaluation present with a specific problem and/or dental emergencies, trauma, acute infections, etc.

Most DDRI contracts allow one oral exam per calendar year. Limited oral evaluations are included in the limitation. Therefore, if a limited oral evaluation is performed prior to an initial or periodic exam in a calendar year, the limited evaluation would be allowed.

D0145 Oral evaluation- CDT: Diagnostic services performed for a child under the age of three, preferably within the first six months of the patient eruption of the first primary tooth, including recording the oral and physical health history, evaluation of caries under 3 years of age susceptibility, development of an appropriate preventive oral health regimen and communication with and counseling of and counseling with the child's parent, legal guardian and/or primary caregiver. primary caregiver a. The time limitation for evaluations is established by group/individual contract and should count towards contractual evaluation limitations. b. D0145 includes any caries susceptibility tests (D0425) or instructions (D1330) on the same date. When performed on the same date as D0145, any fees for D0425 and D1330 are not billable to the patient by a participating dentist. c. For patients under the age of three, any other comprehensive evaluation code submitted (D0150, D0160, D0180) is payable as D0145. Any fees in excess of D0145 are not billable to the patient by a participating dentist. d. Benefits for D0145 for a child over three years of age are considered miscoded and the correct code should be applied.

D0150 Comprehensive oral CDT: Used by a general dentist and/or specialist when evaluating a patient comprehensively. This applies to new evaluation - new or patients; established patients who have had a significant change in health conditions or other unusual circumstances, by established patient report, or established patients who have been absent from active treatment for three or more years .It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.

This includes an evaluation for oral cancer, the evaluation and recording of the patient's dental and medical history and a general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, existing prostheses, occlusal relationships, periodontal conditions (including periodontal screening and/or charting), hard and soft tissue anomalies, etc. a. Comprehensive oral evaluation is paid for the first encounter with the dentist/dental office and subsequent submissions by the same dentist/dental office are paid as periodic oral evaluations determined by the contractual/frequency limitations or level of benefit. b. If the patient has not received any services for three years from the same dentist/dental office a comprehensive evaluation may be benefited.

Delta Dental Utilization Review Guidelines Page 5 1/1/21 D0150 Comprehensive oral evaluation - new or established patient

Rationale: Accepted dental standards indicate that an initial visit should involve a comprehensive oral examination. Subsequent visits will be called periodic and are done on a routine basis. Some subscriber contracts exclude Exams when performed by a Specialist. D0160 Detailed and CDT: A detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive modalities based extensive oral on the findings of a comprehensive oral evaluation. Integration of more extensive diagnostic modalities to develop a evaluation - problem treatment plan for a specific problem is required. The condition requiring this type of evaluation should be described and focused, by report documented.

Examples of conditions requiring this type of evaluation may include dentofacial anomalies, complicated perio-prosthetic conditions, complex temporomandibular dysfunction, facial pain of unknown origin, conditions requiring multi- disciplinary consultation, etc. a. Benefit once per dentist/dental office. b. D0160 counts towards the contractual evaluation limitations.

Limitation: Either one comprehensive oral evaluation (D0150), one detailed and extensive oral evaluation (D0160), or one comprehensive periodontal evaluation (D0180) is allowed in a 36 month period when performed by the same dentist. Some subscriber contracts exclude exams when performed by a specialist. D0170 Re-evaluation -limited, CDT: Assessing the status of a previously existing condition. For example: 1) traumatic injury where no treatment was problem focused rendered but the patient needs follow-up monitoring, 2) evaluation for undiagnosed continuing pain and 3) soft tissue (established patient; lesion requiring follow-up evaluation. not post-op visit) The fees for re-evaluation - limited, problem focused are not billable to the patient in conjunction with another procedure by the same dentist/dental office. Limitation: By definition, this procedure is not to be used for a post­operative visit. By the same logic, this procedure is not to be

D0171 Procedures include all necessary post operative care and re-evaluations. When submitted by the same dentist/dental operative office visit office who performed the original procedure, no payment is made by a participating dentist and the fee is not billable to the patient by a participating dentist. DENY if different dentist/dental office.

D0180 Comprehensive CDT: This procedure is indicated for patients showing signs or symptoms of and for patients with periodontal evaluation risk factors such as smoking or diabetes .It includes evaluation of periodontal conditions, probing and charting, - new or established evaluation and recording of the patient's dental and medical history and general health assessment. It may include the patient evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships & oral cancer evaluation.

a. Time limitations are determined by group/individual contract and should count towards contractual evaluation limitations. b. If a D0180 is submitted with a D4910 on the same date of service by the same dentist/dental office it is benefited as a D0120 and the difference in the approved amount between the D0120 and the D0180 is not billable to the patient by a participating dentist. PRE-DIAGNOSTIC SERVICES D0190 Screening of a patient CDT: A screening including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for diagnosis.

Delta Dental Utilization Review Guidelines Page 6 1/1/21 Counts towards the exam benefit based on the subscriber's contract. When reported in conjunction with an evaluation (D0120, D0140, D0145, D0150, D0160, D0170, D0171, D0180), the fees for assessments are not billable to the patient by a participating dentist as they are integral to the evaluation. When reported individually, include in the frequency cluster for evaluations.

D0191 Assessment of a CDT: A limited clinical inspection that is performed to identify possible signs of oral or systemic disease, malformation, patient or injury, and the potential need for referral for diagnosis and treatment. Counts towards the exam benefit based on the subscriber's contract. When reported in conjunction with an evaluation (D0120, D0140, D0145, D0150, D0160, D0170, D0171, D0180), the fees for assessments are not billable to the patient by a participating dentist as they are integral to the evaluation. When reported individually, include in the frequency cluster for evaluations.

DIAGNOSTIC IMAGING Should only be taken for clinical reasons as determined by the patient's dentist. Should be of diagnostic quality and properly identified and dated, is a part of the patient's clinical record and the original images should be retained by the dentist. Originals should not be used to fulfill requests made by patients or third-parties for copies of records. No payment is made for duplication (copying) of diagnostic images for insurance purposes and the fee is not billable to the patient by a participating dentist. Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist. Image Capture with Interpretation D0210 Intraoral - complete CDT: A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and posterior bitewing images series of radiographic intended to display the crowns and roots of all teeth, periapical areas and alveolar . images

An intraoral complete series or panoramic radiographic image is covered in accordance with the subscriber's contract.

1~ If bitewings (D0720-D0277) /intraoral complete series are taken within the same calendar year by the same dentist/dental office, the fee for the bitewings will be deducted from the intraoral complete series. If the bitewings are submitted after the intraoral complete series has been paid, but during the same calendar year, no payment is made for the bitewings and the same participating dentist/dental office cannot bill the patient.

2~ When benefits are requested for D0330 in conjunction with D0210 by the same dentist/dental office, no payment is made for the D0330 and the fee is not billable to the patient by a participating dentist. The D0330 is considered a component of the D0210 on the same date of service.

3~ No payment is made for a complete series of radiographic images taken on children under the age of 12 and the fee is not billable to the patient by a participating dentist. In order to be considered for payment, the dentist must submit a copy of the radiographic images and a narrative stating the reason the images were taken.

4 - When submitted with intraoral complete series image capture only, the fees for D0709 are not billable to the patient by the same participating dentist/dental office.

Exception: Patients with double Delta Dental of Rhode Island coverage are allowed an additional intraoral complete series in the three or five year period if they meet at least one of the following criteria for dental necessity: 1) Current active periodontal therapy consisting of D4341 at a minimum 2) History of more than 3 root canals 3) Third molars still present and a history of treatment for 4) History of cysts of the jaw D0220 Intraoral - periapical- Definition: first radiographic A diagnostic radiographic image taken prior to a procedure in a limited area of the mouth. image Delta Dental Utilization Review Guidelines Page 7 1/1/21 A diagnostic radiographic image taken to ascertain the presence of is a separate benefit. When submitted with intraoral periapical - image capture only, the fees for D0707 are not billable to the patient by the same participating dentist/dental office. D0230 Intraoral periapical - 1~ Individually listed intraoral radiographic images by the same dentist/dental office are considered an intraoral complete each additional series if the fee for the individual radiographic images equals or exceeds the fee for a complete series done on the same radiographic image date of service. Any fee in excess of the fee for a full mouth series of radiographic images is not billable to the patient by a participating dentist. 2~ Routine, working and final treatment radiographic images taken for endodontic therapy by the same dentist/dental office are considered a component of the complete treatment procedure and separate fees are not billable to the patient by a participating dentist on the same date of service.

3 - When submitted with intraoral periapical - image capture only, the fees for D0707 are not billable to the patient by the same participating dentist/dental office.

No payment is made for D0220 performed on the same date of service as a insertion and the fee is not billable to the patient by a participating dentist. D0240 Intraoral - occlusal Two occlusal radiographic images are allowed in a 12-month period. radiographic image

participating dentist. D0250 Extraoral - 2D CDT: These images include, but are not limited to: Lateral Skull; Posterior-Anterior Skull; Submentovertex; Waters; projection Reverse Tomes; Oblique Mandibular Body; Lateral Ramus. radiographic image created using a DENIED unless covered by group/individual contract. stationary radiation source, and detector

D0251 Extra-oral posterior CDT: Image limited to exposure of complete posterior teeth in both dental arches. This is a unique image that is not dental radiographic derived from another image. image DENIED unless covered by group/individual contract. When submitted with extra-oral posterior image capture only, the fees for D0705 are not billable to the patient by the same participating dentist/dental office. D0270 Bitewing - single Bitewings (2, 3, 4 or vertical) are covered in accordance with the subscriber's contract. radiographic image 1~ If bitewings and intraoral complete series are taken within the same calendar year by the same dentist/dental office, the fee for the bitewings will be deducted from the intraoral complete series. If the bitewings are submitted after the intraoral complete series has been paid, but during the same calendar year, no payment is made for the bitewings and the same participating dentist/dental office cannot bill the patient.

2~ If the fee for the bitewing and the occlusal radiographic images is equal to or exceeds the fee for a full mouth series, it would be considered a full mouth series for payment benefit purposes and time limitations. Any fee in excess of the fee for the full mouth series is not billable to the patient by a participating dentist on the same date of service.

3~ The fee for any type of bitewings submitted with a full mouth series are considered part of the full mouth series for payment and benefit purposes. Any fee in excess of a full mouth series is not billable to the patient by a participating dentist on the same date of service. 4~ If bitewings and a panoramic radiographic image are taken on the same date of service by the same dentist/dental office, process as a complete series - an allowance of an intraoral complete series will be made.

the same participating dentist/dental office.

Delta Dental Utilization Review Guidelines Page 8 1/1/21 D0272 Bitewings - two radiographic images same participating dentist/dental office. D0273 Bitewings - three radiographic images same participating dentist/dental office. D0274 Bitewings - four Exception: radiographic images Patients with double Delta Dental of Rhode Island coverage are allowed an additional set of bitewings in a calendar year if they meet at least one of the following criteria for dental necessity: 1- History of active caries. Previous series of radiographic images resulted in treatment of at least 2 interproximal lesions. 2- Active periodontal therapy consisting of regular periodontal probings and receiving at least service D4910 (and all more aggressive periodontal therapy). 3- Radiation therapy to the head and neck during the previous six months. A narrative must be submitted for DCM to review. If no narrative, the claim will deny up front.

the same participating dentist/dental office.

Limit two bitewing images for patients under 10. D0273 (three bitewing x-rays) or D0274 (four bitewing x-rays) submitted for a patient under age 10 will be processed as D0272 (two bitewing x-rays) and the excess fees of D0272 are not billable to the patient by a participating dentist. D0277 Vertical bitewings - 7 CDT: This does not constitute a full mouth intraoral radiographic series. to 8 radiographic images Vertical bitewings are considered bitewings for benefit purposes and are subject to the time limit frequencies for bitewing radiographic images in the contract. If the fee for the vertical bitewings is equal to or exceeds the fee for full mouth series, it would be considered a full mouth series for payment benefit purposes and time limitations. Any fee in excess of the fee for full mouth series of radiographic images is not billable to the patient by a participating dentist on the same date of service.

D0310 Sialography Subject to a 60 month time limitation D0320 Temporomandibular Subject to a 60 month time limitation joint arthrogram, including injection D0321 Other Subject to a 60 month time limitation radiographic images, by report D0322 Tomographic survey DENIED unless covered by group/individual contract. D0330 Panoramic a. An intraoral complete series or panoramic radiographic image is covered in accordance with the subscriber's contract. radiographic image b. A panoramic radiographic image, with or without supplemental radiographic images (such as periapicals, bitewings and/or occlusal), is considered a complete series for time limitations and any fee in excess of the fee allowed for D0210 is not billable to the patient by a participating dentist on the same date of service. c. When benefits are requested for D0330 in conjunction with D0210 by the same dentist/dental office, no payment is made for the D0330 and the fee is not billable to the patient by a participating dentist. The D0330 is considered a component of the D0210 on the same date of service. d. Benefits for subsequent panoramic radiographic images taken within the contractual time limitation for a full mouth series are denied. e. A panoramic film is a benefit for individuals ages 6 and older. f. When submitted with panoramic image capture only, the fees for D0701 are not billable to the patient by the same participating dentist/dental office.

Delta Dental Utilization Review Guidelines Page 9 1/1/21 Dental Consultant Criteria/Notes: Exceptions: - When medically necessary for the diagnosis and/or follow-up of oral and maxillofacial pathology and trauma (documentation required). - When medically necessary for the diagnosis and treatment of symptomatic third molars if root formation is incomplete at time of previous panoramic film (documentation may be requested). - Once every three years for children who cannot cooperate for intraoral film due to developmental disability or medical condition that does not allow for intraoral film placement.

D0340 2D Cephalometric CDT: Image of the head made using a cephalostat to standardize anatomic positioning, and with reproducible x-ray beam geometry. acquisition, measurement and analysis

a. Cephalometric radiographic image is payable only in conjunction with orthodontic benefits. b. Benefits for a cephalometric radiographic image not taken in conjunction with orthodontic treatment are DENIED. c. When submitted with the 2D cephalometric image capture only, the fees for D0702 are not billable to the patient by the same participating dentist/dental office.

D0350 2D Oral/facial a. Benefits for oral/facial images may be paid once per case as orthodontic records. Fees for additional oral/facial photographic images images by the same dentist/dental office are not billable to the patient by a participating dentist once per lifetime. obtained intraorally or b. Benefits for oral/facial images for other procedures are considered elective and therefore are DENIED. extraorally c. When submitted with 2-D oral/facial photographic image, the fees for D0703 are not billable to the patient by the same participating dentist/dental office.

D0351 3D photographic CDT: This procedure is for dental or maxillofacial diagnostic purposes. Not applicable for a CAD-CAM procedure. image 3D photographic images are DENIED as a specialized procedure. When submitted with 3-D photographic image, the fees for D0703 are not billable to the patient by the same participating dentist/dental office.

D0364 Cone beam CT a. The benefit for Cone Beam CT capture and interpretation of view restricted to less than one whole jaw is DENIED capture and unless covered by group individual contract. When covered, benefit once per 12 months. interpretation with b. When submitted in conjunction with the capture only procedure D0380, the fee for D0380 is not billable to the patient limited field of view- by a participating dentist. less than one whole c. When submitted in conjunction with the interpretation procedure D0391, the fee for D0391 is not billable to the patient jaw by a participating dentist. Interpretation: Allow one CBCT per benefit year. Cross check against D0364, 0365, 0366, and 0367.

D0365 Cone beam CT a. The benefit for cone beam CT capture and interpretation with field of view of one full arch- is DENIED unless capture and covered by group/individual contract. interpretation with b. Benefits are DENIED if D0364 D0366, D0367 were benefitted in the last 12 months. field of view of one c. When submitted in conjunction with the capture only procedure D0381, the fee for D0381 is not billable to the patient full dental arch - by a participating dentist. mandible d. When submitted in conjunction with the interpretation procedure D0391, the fee for D0391 is not billable to the patient by a participating dentist. Interpretation: Cross check against D0364, D0365, D0366 and D0367.

Delta Dental Utilization Review Guidelines Page 10 1/1/21 D0366 Cone beam CT capture and DENIED unless covered by group/individual contract. When covered, benefit once per 12 months. interpretation with b. Benefits are DENIED if D0364, D0365, D0366, D0367 were benefitted in the last 12 months. field of view one full c. When submitted in conjunction with the capture only procedure D0382, the fee for D0382 is not billable to the patient by a participating dentist. with or without d. When submitted in conjunction with the interpretation procedure D0391, the fee for D0391 is not billable to the patient cranium by a participating dentist. Interpretation: Cross check against D0364, D0365, D0366 and D0367.

D0367 Cone beam CT a. Cone beam CT capture and interpretation with field of view of both jaws with or without cranium is DENIED unless capture and covered by group/individual contract. When covered, benefit once per 12 months. interpretation with b. Benefits are DENIED if D0364, D0365, D0366, D0367 were benefitted in the last 12 months. field of view of both c. When submitted in conjunction with the capture only procedure D0383, the fee for D0383 is not billable to the patient jaws, with or without by a participating dentist. cranium d. When submitted in conjunction with the interpretation procedure D0391, the fee for D0391 is not billable to the patient by a participating dentist. Interpretation: Cross check against D0364, D0365, D0366 and D0367.

D0368 Cone beam CT a. Cone beam CT capture and interpretation for TMJ series including two or more exposures is DENIED unless covered capture and by group/individual contract includes TMJ coverage. When covered, benefit once per lifetime. interpretation for TMJ b. When submitted in conjunction with the capture only procedure D0384, the fee for D0384 is not billable to the patient series including two or by a participating dentist. more exposures c. When submitted in conjunction with the interpretation procedure D0391, the fee for D0391 is not billable to the patient by a participating dentist. Interpretation: Cross check against itself, D0368.

D0369 Maxillofacial MRI DENIED unless covered by group/individual contract. capture and interpretation D0370 Maxillofacial DENIED unless covered by group/individual contract. ultrasound capture and interpretation D0371 Sialoendoscopy DENIED unless covered by group/individual contract. capture and interpretation Image Capture Only

Capture by a Practitioner not associated with Interpretation and Report

D0380 Cone beam CT image DENIED unless covered by group/individual contract. capture with limited

than one whole jaw

D0381 Cone beam CT image DENIED unless covered by group/individual contract. capture with field of view of one full dental

Delta Dental Utilization Review Guidelines Page 11 1/1/21 D0382 Cone beam CT image DENIED unless covered by group/individual contract. capture with field of view one full dental

without cranium

D0383 Cone beam CT image DENIED unless covered by group/individual contract. capture with field of view of both jaws, with or without cranium

D0384 Cone beam CT DENIED unless covered by group/individual contract. capture images for TMJ series including two or more exposures

D0385 Maxillofacial MRI DENIED unless covered by group/individual contract. image capture D0386 Maxillofacial DENIED unless covered by group/individual contract. ultrasound image capture

D0701 Panoramic The fee for a panoramic image capture only is considered part of D0330 and is not billable to the patient by a participating dentist. image capture only D0702 2-D cephalometric The fee for a 2D cephalometric image capture only is considered part of D0340 and is not billable to the patient by a participating dentist. image capture only D0703 2-D oral/facial The fee for 2-D oral/facial photographic image capture only is considered part of D0350 and is not billable to the patient photographic image by a participating dentist. obtained intra-orally

image capture only

D0704 3-D photographic

capture only

D0705 Extra-oral posterior Image limited to exposure of complete posterior teeth in both dental arches. This is a unique image that is not derived dental radiographic from another image.

capture only The fee for the extra-oral posterior- image capture only is considered part of D0251 and is not billable to the patient by a participating dentist.

D0706 participating dentist. image capture only

Delta Dental Utilization Review Guidelines Page 12 1/1/21 D0707 patient by a participating dentist. image capture only D0708 CDT: Image axis may be horizontal or vertical.

image capture only

billable to the patient by a participating dentist. D0709 CDT: A radiographic survey of the whole mouth, usually consisting of 14-22 images (periapical and posterior bitewing as series of radiographic indicated) intended to display the crowns and roots of all teeth, periapical areas and alveolar bone.

capture only The fee for intraoral complete series image - capture only is considered part of D0210 and is not billable to the patient by a participating dentist. Interpretation and Report Only

Interpretation and Report by a Practitioner not associated with Image Capture

D0391 Interpretation of DENIED unless covered by group/individual contract. diagnostic image by a practitioner not associated with capture of the image, including report

Post Processing of Image or Image Sets D0393 Treatment simulation CDT: The use of 3D image volumes for simulation of treatment including, but not limited to, placement, using 3D image orthognathic surgery and orthodontic tooth movement. volume DENIED as a specialized technique.

D0394 Digital subtraction of CDT: To demonstrate changes that have occurred over time. two or more images DENIED as a specialized technique. or image volumes of the same modality D0395 Fusion of two or more DENIED as a specialized technique. 3D image volumes of one or more modalities TESTS AND EXAMINATIONS D0411 HbA1c in-office point a. DENIED unless covered by group/individual contract. of service testing b. When covered by group contract, limited to one test per benefit year. c. When D0411 is submitted on the same date/same dentist/dental office as D0412 (blood level glucose level test), no payment is made for the D0412 and the fee is not billable to the patient by a participating dentist. D0412 Blood glucose level CDT: the point-of-service analysis. glucose meter

Delta Dental Utilization Review Guidelines Page 13 1/1/21 a. Benefits are DENIED unless covered by group/individual contract. b. No payment is made for D0412 and the fee is not billable to the patient by a participating dentist on the same day as D0411.

D0414 Laboratory processing Benefits for laboratory processing of microbial specimens are DENIED unless covered by the group/individual contract. of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report

D0415 Collection of DENIED unless covered by group/individual contract. For those groups with coverage, this procedure is limited to once microorganisms for per calendar year. culture and sensitivity

D0416 Viral Culture CDT: A diagnostic test to identify viral organisms, most often herpes virus. DENIED unless covered by group/individual contract. D0417 Collection and DENIED unless covered by group/individual contract. preparation of saliva sample for laboratory diagnostic testing D0418 Analysis of saliva DENIED unless covered by group/individual contract. sample D0419 Assessment of CDT: This procedure is for identification of low salivary flow in patients at risk for hyposalivation and xerostomia, as well salivary flow by as effectiveness of pharmacological agents used to stimulate saliva production. measurement

DENIED unless covered by group/individual contract. If covered, limited to one assessment every three years. Subsequent submissions are not billable to the patient within 12 months and DENIED between 12 and 36 months.

D0422 Collection and DENIED unless covered by group/individual contract. preparation of genetic sample material for laboratory analysis and report

D0423 Genetic test for CDT: Certified laboratory analysis to detect specific genetic variations associated with increased susceptibility for susceptibility to diseases.

analysis DENIED unless covered by group/individual contract. D0425 Caries susceptibility CDT: Not to be used for carious staining. test DENIED unless covered by group/individual contract. For those groups with coverage, this procedure is limited to once in a lifetime.

Delta Dental Utilization Review Guidelines Page 14 1/1/21 D0431 Adjunctive pre- DENIED unless covered by group/individual contract. diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

D0460 vitality tests CDT: Includes multiple teeth and contra lateral comparison(s), as indicated. Pulp vitality tests are payable per visit, not per tooth, and only for the diagnosis of emergency conditions. No payment is made, and the fees are not billable to the patient by a participating dentist for pulp tests as it is considered part of any other definitive procedure on the same day, by the same dentist/dental office except limited oral evaluation-problem focused (D0140), palliative treatment (D9110), radiographic images (D0210 - D0391), consultation (D9310) and sedative filling (D2940).

D0470 Diagnostic casts CDT: Also known as diagnostic models or study models. a. Diagnostic casts are payable only once when performed in conjunction with orthodontic services. Additional casts taken by the same dentist/dental office during or after orthodontic treatment are included in the fee for orthodontics and separate fees are not billable to the patient by a participating dentist. Benefit once per lifetime. b. Benefits for diagnostic casts taken in conjunction with any other procedure are DENIED.

D0600 Non-ionizing a. No payment is made for D0600 and the fees are not billable to the patient by a participating dentist when submitted diagnostic procedure with an evaluation. capable of b. When submitted separately from an evaluation, diagnostic monitoring benefits are DENIED. quantifying, Rationale: monitoring, and 1. Non-ionizing diagnostic monitoring of dental tissues is considered part of an oral evaluation and should be included in recording changes in the evaluation fee. structure of enamel, 2. Investigational until sufficient longitudinal data is available or unless covered by group/individual contract. dentin, and

D0601 Caries risk assessment CDT: Using recognized assessment tools. and documentation, DENIED unless covered by group/individual contract. with a finding of low risk If covered: a. Not billable to the patient by a participating dentist when submitted for children under the age of three. b. Limited to one risk assessment 12 months. Subsequent risk assessment codes submissions are not billable to the patient by a participating dentist within 12 months. c. Not billable to the patient by a participating dentist when submitted with other risk assessment codes on the same date of service by the same dentist/dental office. D0602 Caries risk assessment CDT: Using recognized assessment tools. and documentation, DENIED unless covered by group/individual contract. with a finding of moderate risk

Delta Dental Utilization Review Guidelines Page 15 1/1/21 If covered: a. Not billable to the patient by a participating dentist when submitted for children under the age of three. b. Limited to one risk assessment every 12 months. Subsequent risk assessment codes submissions are not billable to the patient by a participating dentist within 12 months. c. Not billable to the patient by a participating dentist when submitted with other risk assessment codes on the same date of service by the same dentist/dental office.

D0603 Caries risk assessment CDT: Using recognized assessment tools. and documentation, DENIED unless covered by group/individual contract. with a finding of high risk

If covered: a. Not billable to the patient by a participating dentist when submitted for children under the age of three. b. Limited to one risk assessment every 12 months. Subsequent risk assessment codes submissions are not billable to the patient by a participating dentist within 12 months. c. Not billable to the patient by a participating dentist when submitted with other risk assessment codes on the same date of service by the same dentist/dental office.

If D0601, D0602 or D0603 is covered, the dentist must utilize a recognized caries risk assessment tool to record data and document results. Recognized tools include: PreViser, Cambra, CAT, ADA, Cariogram D0604 Antigen testing for a Benefits are DENIED unless covered by group/individual contract. public health related Rationale: Subject to coverage under the medical plan. pathogen, including coronavirus D0605 Antibody testing for a Benefits are DENIED unless covered by group/individual contract. public health related Rationale: Subject to coverage under the medical plan. pathogen, including coronavirus

ORAL PATHOLOGY LABORATORY These procedures do not include collection of the tissue sample, which is documented separately. D0472 Accession of tissue, CDT: To be used in reporting architecturally intact tissue obtained by invasive means. gross examination, See D0472-D0480, D0486 policy below. preparation and transmission of written report

D0473 Accession of tissue, CDT: To be used in reporting architecturally intact tissue obtained by invasive means. gross and microscopic See D0472-D0480, D0486 policy below. examination, preparation and transmission of written report

Delta Dental Utilization Review Guidelines Page 16 1/1/21 D0474 Accession of tissue, CDT: To be used in reporting architecturally intact tissue obtained by invasive means. gross and microscopic See D0472-D0480, D0486 policy below. examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0480 Accession of CDT: To be used in reporting disaggregated, non-transepithelial cell cytology sample via mild scraping of the oral exfoliative cytologic mucosa. smears, microscopic See D0472-D0480, D0486 policy below. examination, preparation and transmission of written report D0486 Laboratory accession CDT: Analysis, and written report of findings, of cytologic sample of disaggregated transepithelial cells. of transepithelial See D0472-D0480, D0486 policy below. cytologic sample, microscopic examination, preparation and transmission of written report D0475 Decalcification CDT: Procedure in which hard tissue is processed in order to allow sectioning and subsequent microscopic examination. procedure See D0472-D0480, D0486 policy below.

D0476 Special stains for CDT: Procedure in which additional stains are applied to a biopsy or surgical specimen in order to identify microorganisms microorganisms. See D0472-D0480, D0486 policy below. D0477 Special stains, not for CDT: Procedure in which additional stains are applied to a biopsy or surgical specimen in order to identify such things as microorganisms melanin, mucin, iron, glycogen, etc. See D0472-D0480, D0486 policy below.

D0478 Immunohistochemical CDT: A procedure in which specific antibody based reagents are applied to tissue samples in order to facilitate stains diagnosis. See D0472-D0480, D0486 policy below. D0479 Tissue in-situ CDT: A procedure that allows for the identification of nucleic acids, DNA and RNA, in the tissue sample in order to aid in hybridization, the diagnosis of microorganisms and tumors. including See D0472-D0480, D0486 policy below. interpretation D0472-D0480, D0486 policy: a. These procedures must be accompanied by a pathology report. If the procedure is not accompanied by a pathology report, no payment is made and the fee for the procedure is not billable to the patient by a participating dentist. b. If more than one of these procedures is submitted on the same day, same site by the same dentist/dental office, benefits are allowed for the most inclusive procedure and the less inclusive procedure is not billable to the patient by a participating dentist.

Delta Dental Utilization Review Guidelines Page 17 1/1/21 D0481 Electron microscopy See D0481-D0483 policy below D0482 Direct CDT: A technique used to identify immunoreactants that are localized to the patient's skin or mucous membranes. immunofluorescence See D0481-D0483 below

D0483 Indirect CDT: A technique used to identify circulating immunoreactants. immunofluorescence See D0481-D0483 policy below D0481-D0483 policy: Pathology reports, procedures D0472, D0473, D0474 and D0480 include preparation of tissue (sectioning, staining, etc.) and gross and microscopic evaluation. The fees for D0475 through D0483 are not billable to the patient by a participating dentist as they are a component of the pathology procedures. D0484 Consultation on slides CDT: A service provided in which microscopic slides of a biopsy specimen prepared at another laboratory are evaluated prepared elsewhere to aid in the diagnosis of a difficult case or to offer a consultative opinion at the patient's request. The findings are delivered by written report. D0484 is benefited as D9310 (diagnostic service provided by dentist or physician other than practitioner providing treatment). D0485 Consultation, CDT: A service that requires the consulting pathologist to prepare the slides as well as render a written report. The slides including preparation are evaluated to aid in the diagnosis of a difficult case or to offer a consultative opinion at the patient's request. of slides from biopsy material supplied by a. D0485 must be accompanied by a pathology report. If the procedure is not accompanied by a pathology report the referring source fee for the procedure is not billable to the patient by a participating dentist. b. When billed on the same day, same site by the same dentist/dental office, benefits are allowed for the most inclusive procedure and the less inclusive procedure is not billable to the patient by a participating dentist. c. When multiple procedures are submitted in the same area of the mouth, the more complex would be a benefit. The fees for subsequent procedure codes would be not billable to the patient by a participating dentist.

D0502 Other oral pathology Other oral pathology procedures must be accompanied by a pathology report. The fee for D0502 submitted without the procedures, by report report are not billable to the patient by a participating dentist.

D0999 Unspecified CDT: Used for procedure that is not adequately described by a code. Describe procedure. Narrative diagnostic procedure, by report 1.The information submitted, specifically the narrative, should be reviewed for its content and translated to a recognized code if possible. For example, if information is submitted under D4999 and it is determined that a was performed, the code should be changed to a D4211 and processed accordingly. 2. If, however, an unusual procedure was performed for which there is no code, the narrative should be reviewed along

on both the degree of difficulty and the time involved. PREVENTIVE D1000-D1999 DENTAL PROPHYLAXIS

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

D1110 Prophylaxis-adult CDT: Removal of plaque, and stains from the tooth structures and implants in the permanent and transitional dentition. It is intended to control local irritational factors. Considered an adult prophylaxis age 14 and older.

Delta Dental Utilization Review Guidelines Page 18 1/1/21 Limitation: Most contracts provide for two cleanings in a calendar/policy year period; some contracts allow one every 6 months.

Exception: The average dental patient requires two prophylaxes per year. Any patient requiring more than this has a need that is outside the average. Additional prophylaxis can be done when the patient agrees to assume the additional cost.

Upon DCM review, patients with double Delta Dental of Rhode Island coverage may be eligible for up to 2 additional (4 total/year) prophylaxes if dentally necessary. A narrative is required stating that the patient exhibits at least one of the following conditions: 1) More than 4 sites, but no pocketing; 2) History of caries treatment at each of the last 2 visits; 3) More than 2 sites exhibit pockets 4mm or greater. If criteria is not met, deny. A prophylaxis done on the same date by the same dentist/dental office as a periodontal maintenance, scaling or root planing D4341 or periodontal surgery is considered to be part of and included in those procedures and the fee is not billable to the patient by a participating dentist.

If a D4342 is performed on the same date as a D1110 or D4346, the fee for both procedures may be benefited. When submitted with D4346, no payment is made for D1110 and the fee is not billable to the patient by the same participating dentist/dental office. D1120 Prophylaxis-child CDT: Removal of plaque, calculus and stains from the tooth structures and implants in the primary and transitional dentition. It is intended to control local irritational factors. Considered a child prophylaxis up to, but not including their 14th birthday.

When submitted with D4346, no payment is made for D1120 and the fee is not billable to the patient by the same participating dentist/dental office. TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE) Prescription strength fluoride product designed solely for use in the dental office, delivered to the dentition under the direct supervision of a dental professional. Fluoride must be applied separately from prophylaxis paste. General Policy - Benefits for fluoride treatments are defined by the group/individual contract.

General Policy - Using prophylaxis paste containing fluoride or a fluoride rinse or swish in conjunction with a prophylaxis is considered a prophylaxis only. A separate fee for this type of topical fluoride application is not billable to the patient by a participating dentist. D1206 Topical application of 1-Benefits for D1208 topical application of fluoride and D1206 are interchangeable. For example: If a member has fluoride varnish coverage for one fluoride treatment per year, they would be eligible for either one D1208 or one D1206. 2-If D1206 is covered by the subscriber's contract (EBD Plan), benefit once every 12 months for patients over age 16 following gingival flap or osseous surgery. Benefits for topical fluoride treatments are defined by subscriber contract. Benefits for topical fluoride varnish when used for desensitization or as cavity liners are DENIED. D1208 Topical application of Most subscriber contracts cover one (1) topical application of fluoride per 12 months for covered dependents up to, but not including their 19th birthday (prophylaxis not included). Fluoride must be applied separately from prophylaxis paste. varnish Topical fluoride for an adult is denied unless covered by group/individual contract. Patients with double Delta Dental of Rhode Island coverage can be covered for an additional topical application per calendar year. Fluoride gels, rinses, tablets, or other preparations intended for home application are DENIED unless covered by contract. Using prophylaxis paste containing fluoride or a fluoride rinse or swish in conjunction with a prophylaxis is considered a prophylaxis only. A separate fee for this type of topical fluoride application is not billable to the patient on the same date of service or by the same participating dentist/dental office as a prophylaxis.

Delta Dental Utilization Review Guidelines Page 19 1/1/21 OTHER PREVENTIVE SERVICES D1310 Nutritional counseling CDT: Counseling on food selection and dietary habits as a part of treatment and control of periodontal disease and for control of dental caries. disease DENIED unless covered by group/individual contract.

D1320 Tobacco counseling CDT: Tobacco prevention and cessation services reduce patient risks of developing tobacco-related oral diseases and for the control and conditions and improves prognosis for certain dental therapies. prevention of oral DENIED unless covered by group/individual contract. disease D1321 Counseling for the CDT: Counseling services may include patient education about adverse oral, behavioral, and systemic effects associated control and with high-risk substance use and administration routes. This includes ingesting, injecting, inhaling and vaping. Substances prevention of adverse used in a high-risk manner may include but are not limited to alcohol, opioids, nicotine, cannabis, methamphetamine and oral, behavioral, and other pharmaceuticals or chemicals. systemic health DENIED unless covered by group/individual contract. effects associated with high-risk substance use

D1330 Oral hygiene DENIED unless covered by group/individual contract. instruction

D1351 Sealant-per tooth CDT: Mechanically and/or chemically prepared enamel surface sealed to prevent decay. General Policy - Sealants are a benefit once per tooth on the occlusal surface of permanent molars. Benefit is subject to a time limitation (per contract) per unrestored tooth and includes all necessary repair or replacement. For those contracts with a 24 month time limitation: If repair/replacement is submitted within 24 months from initial application, no payment is made and the same participating dentist/dental office cannot bill the patient. The repair/replacement is denied for a non-participating or different dentist/dental office. For those contracts with a 36 month time limitation: If repair/replacement is submitted from 0-24 months from initial application, no payment is made and the same participating dentist/dental office cannot bill the patient. The repair/replacement is denied for a non- participating or different dentist/dental office. If repair/replacement is submitted from 24-36 months from initial application, the procedure will be denied. For patients beyond the age limit, special consideration can be given for delayed eruption upon appeal with submission of a narrative.

Fees for sealants completed on the same date of service and on the same surface as a restoration by the same participating dentist/dental office are not billable to the patient and are considered a component of the restoration.

Delta Dental Utilization Review Guidelines Page 20 1/1/21 D1353 General Policy - Benefits for sealants include repair or replacement within 24 months by the same dentist/dental office. tooth No payment is made for the repair or replacement of a sealant and the fees are not billable to the patient by a participating dentist if performed within 24 months of initial placement by same dentist/dental office. a. Fees for repairing sealants completed on the same date of service and on the same surface as a restoration by the same dentist/dental office are not billable to the patient by a participating dentist and are considered a component of the restoration.

restoration on the occlusal surface of the same tooth. c. Benefits for sealants include repair or replacement within 24 months by the same dentist/dental office. No payment is made for the repair or replacement of a sealant and the fees are not billable to the patient by a participating dentist if performed within 24 months of initial placement by the same dentist/dental office. d. Benefits for repairing sealants requested 24 months or more following the initial placement are DENIED or covered based on group/individual contract.

D1352 Preventive resin CDT: Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes restoration in a placement of a sealant in any radiating non-carious fissures or pits. moderate to high caries risk patient- permanent tooth

a. Fees for preventive resin restoration completed on the same date of service and on the same surface as a restoration by the same dentist/dental office are considered a component of the restoration and are not billable to the patient by a participating dentist. b. Benefits for preventive resin restorations are DENIED when submitted documentation or the patient's claim history indicates a restoration on the occlusal surface of the same tooth. c. Age limitations for preventive resin restorations are determined by group/individual contract. d. Preventive resins restorations are payable once per tooth on the occlusal surface of permanent molars for patients through age 15. The teeth must be free from overt dentinal caries e. Benefits for preventive resin restorations or sealants include repair or replacement within 24 months by the same dentist/dental office. Fees for repair or replacement of a preventive resin restoration are not billable to the patient by a participating dentist if performed within 24 months of initial placement by the same dentist/dental office. f. Benefits for preventive resin restorations requested after 24 months are DENIED or covered based on group/individual contract.

D1354 Interim caries CDT: Conservative treatment of an active, non-symptomatic carious lesion by topical application of a caries arresting or arresting medicament inhibiting medicament and without mechanical removal of sound tooth structure. application - per tooth

a. Benefits are limited to twice per tooth per benefit year. b. Benefits for more than twice per tooth per benefit year are DENIED. c. Fees for D1354 on the same date of service as a restoration are not billable to the patient by a participating dentist. d. Benefits for restorations placed within 3 months of D1354 are DENIED. e. D1354 does not count against fluoride frequency.

Dentists Criteria/Notes: 1.) Used to arrest dentinal and cervical caries. 2.) This procedure can be used to report both Silver Diamine Fluoride and Silver Nitrate. 3.) No limit on the number of teeth that can be treated per day.

Delta Dental Utilization Review Guidelines Page 21 1/1/21 D1355 Caries preventive CDT: For primary prevention or remineralization. Medicaments applied do not include topical fluorides. medicament DENIED unless covered by group/individual contract.

tooth

SPACE MAINTENANCE (Passive Appliances) Passive appliances are designed to prevent tooth movement Space maintainers are used to retain space for the eruption of permanent teeth when the primary teeth are lost prematurely. Most permanent teeth erupt by the age of 14 years.

D1510 Space maintainer- CDT: Excludes a distal shoe space maintainer. Indicate quadrant Only one unilateral space maintainer is benefited per quadrant, per lifetime except under unusual circumstances. quadrant Otherwise, benefits are DENIED. D1516 Space maintainers are a benefit for covered dependents up to, but not including their 14th birthday and are payable upon placement. Benefits will be provided for one space maintainer in 60 months in the same area. maxillary D1517 Space maintainers are not a benefit on anterior teeth (central and lateral incisors).

mandibular D1520 Space maintainer- Only one unilateral space maintainer is benefited per quadrant, per lifetime except under unusual circumstances. Indicate quadrant removable, unilateral - Otherwise, benefits are DENIED. per quadrant

D1526 There is no separate benefit for a stainless steel or resin crown when used as part of the space maintainer.

maxillary

D1527 Rationale: A space maintainer will normally perform its function during the time needed without replacement if fitted and cemented correctly. It is the rare case that requires replacement because of oral changes due to growth. Lost, mandibular broken or stolen appliances are not a benefit and are the patient's responsibility. D1551 Re-cement or re-bond a. One recementation or re-bonding is allowed per space maintainer per arch. bilateral space b. Benefits for subsequent requests for recementation or re-bonding are DENIED. maintainer - maxillary

D1552 Re-cement or re-bond a. One recementation or re-bonding is allowed per space maintainer per arch. bilateral space b. Benefits for subsequent requests for recementation or re-bonding are DENIED. maintainer - mandibular D1553 Re-cement or re-bond a. One recementation or re-bonding is allowed per space maintainer, per quadrant. Indicate quadrant unilateral space b. Benefits for subsequent requests for recementation or re-bonding are DENIED. maintainer - per quadrant D1556 Removal of fixed a. Fees for removal of fixed space maintainer by the same dentist/dental office who placed appliance are not billable to unilateral space the patient by a participating dentist anytime following placement of space maintainer. maintainer - per b. D1556 is not billable to the patient by a participating dentist when submitted with recementation done on the same quadrant date of service. c. Fees for removal of a fixed space maintainer by a different dentist/office than who placed the appliance are DENIED.

Delta Dental Utilization Review Guidelines Page 22 1/1/21 D1557 Removal of fixed a. Fees for removal of fixed space maintainer by the same dentist/dental office who placed the appliance are not billable bilateral space to the patient by a participating dentist anytime following placement of space maintainer. maintainer - maxillary b. D1557 is not billable to the patient by a participating dentist when submitted with recementation done on the same date of service. c. Fees for removal of a fixed space maintainer by a different dentist/office than who placed the appliance are DENIED.

D1558 Removal of fixed a. Fees for removal of fixed space maintainer by the same dentist/dental office who placed the appliance are not billable bilateral space to the patient by a participating dentist anytime following placement of space maintainer. maintainer - b. D1558 not billable to the patient by a participating dentist when submitted with recementation done on the same date mandibular of service. c. Fees for removal of a fixed space maintainer by a different dentist/office than who placed the appliance are DENIED.

SPACE MAINTAINERS D1575 Distal shoe space CDT: Fabrication and delivery of fixed appliance extending subgingivally and distally to guide the eruption of the first Indicate quadrant permanent molar. Does not include ongoing follow-up or adjustments, or replacement appliances, once the tooth has unilateral - per erupted. quadrant a. Limited to children 8 and younger. b. No payment is made for the for repairs and adjustments by same dentist/dental office and the fees are not billable to the patient by a participating dentist. Dental Consultant Criteria/Note: This is limited to guiding eruption of first permanent molars. A follow-up space maintainer, can be considered. Dental Consultant Criteria/Note: This is limited to guiding eruption of first permanent molars. A follow-up space maintainer, can be considered.

D1999 Unspecified CDT: Used for procedure that is not adequately described by another CDT Code. Describe procedure. Narrative preventive procedure, May require IC review by Dental Consultant. by report RESTORATIVE D2000-D2999 Location Number of Characteristics Surfaces 1 2 Anterior 3 4 or more 1 2 Posterior 3 4 or more Note: Tooth surfaces are reported on the HIPAA standard electronic dental transaction and the ADA Dental Claim Form using the letters in the following table. Surface Code Buccal B Distal D Facial (or F Labial) Incisal I

Delta Dental Utilization Review Guidelines Page 23 1/1/21 Lingual L Mesial M Occlusal O **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.**

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

The term specialized procedure describes a dental service or procedure that is used when unusual or extraordinary circumstances exist and is not generally used when conventional methods are adequate. AMALGAM RESTORATIONS (Including Polishing) Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration. If pins are used, they should be reported separately (see D2951).

Limit of One Restoration Per Surface: Payment is made for one restoration in each tooth surface irrespective of the number or combination of restorations placed. A separate charge may not be made to the patient by a participating dentist. Ex: Dentist submits for tooth #3 O (pit) and again #3 O (pit) on the same claim form. Delta Dental will reimburse for one restoration, #3 O. General Policy - If an indirectly fabricated restoration is performed, by the same dentist/dental office within 24 months of the placement of an amalgam or composite restoration, the benefit and patient co-payment allowance for the amalgam or composite restorations will be deducted from an indirectly fabricated restoration benefit.

General Policy - No payment will be made for the replacement of amalgam or composite restorations within 24 months and the fees are not billable to the patient if done by the same dentist/dental office. Benefits may be allowed if done by a different dentist/dental office. Special consideration may be given by report.

Restorations for altering involving vertical dimension and the replacement of tooth structure lost due to , erosion, , , corrosion and TMD are denied. Exception - Class V (facial or lingual surface) restorations are allowed when these conditions are present. An amalgam or resin restoration placed the same day as a crown on the same tooth is considered part of the procedure and is not billable to the patient by a participating dentist. If the dentist submits for a single surface filling after the crown is placed, pay for the filling. No payment will be made for A multi-surface filling after the crown is placed and the fee is not billable to the patient by a participating dentist.

Payment for restorations on posterior teeth not involving the occlusal surface (O) performed on the same day by the same dentist/dental office will be limited to that of a one surface restoration. Exception: A submission for a single tooth with a buccal (B) and lingual (L) surface restorations (non-contiguous surfaces) will be benefited as either: a) a two-

Class V restorations (anterior/posterior teeth) are considered to be a single surface restoration, except in the case of a

dentist.

Examples (if submitted as, will pay as):

Posterior restorations involving the proximal and the occlusal surfaces are considered one restoration for payment purposes.

Delta Dental Utilization Review Guidelines Page 24 1/1/21 done on the same day as a restoration are considered part of the procedure and a separate charge may not be made to the patient (except in the case of a Class V restoration; gingivectomy is allowed on the same day in this instance). Any restoration that involves the replacement of a surface previously restored within 24 months will be adjusted to pay only the new surface involved. Exception: If endo treatment is performed within the 24 months, another restoration will be allowed regardless of surfaces involved. I.C. Reviews for Replacement of Amalgam/Composites within 24 months. Criteria for determining if Delta Dental should benefit the procedure: I.C. Reviews for Replacement of Multi-surface Anterior Teeth Which Involve the Incisal Edge (Procedure Code D2335) ~ Traumatic Injury within 24 months Delta will benefit the restoration once for initial placement. One additional replacement restoration within 24 months will be considered upon appeal on an IC basis. ~ Additional Interproximal Decay within 24 months If a Class II restoration is placed and within 24 months, there is additional decay on the other proximal surface that was not present on the original bitewing, a new 3-surface restoration should be benefited. This should be supported by a bitewing radiograph exhibiting the new area of decay or by a treatment noted, detailing the area of new decay and

~ Broken cusp within 24 months If a large restoration is placed (ex: MOD) and within 24 months a cusp fractures, the Dental Consultant should review the case on an IC basis. Consideration should be given for a new 4-surface restoration (MODL, MODB). When a 3-surface restoration is wide, the integrity of the supporting buccal/lingual cusps is compromised and is subject to fracture.

~ Patient with medical disorder The patient has a medical disorder that interferes with ideal placement of a restoration. Examples of this may include a

medications that may cause dry mouth as a side effect. ~ Bruxer The patient who is a severe bruxer may need more frequent replacement of fillings since the teeth are shorter and afford less mechanical retention as well as the constant pressure of grinding on the existing restorations. · Partial denture Teeth that may be supporting a partial denture where the clasps attach. ~ Upper denture Lower anterior teeth with no posterior dentition that are supporting an upper denture. ~ Unsupported tooth structure A large multi-surfaced restoration on a posterior tooth where unsupported remaining tooth structure continues to fracture ~ Other instances may arise Cases in which a patient is responsible: ~ Patient non-compliance When the dentist has recommended a crown on a tooth with a large restoration but the patient has declined or delays the treatment. When patient has documented poor home care and recurrent decay/fractures, etc., are not within the control of the dentist. Patient refuses to remove partials at night; other habits that contribute to the early breakdown of a restoration. Other Reviews: (Usually bundled on original processing)

Delta Dental Utilization Review Guidelines Page 25 1/1/21 In cases of multiple restorations involving the proximal and occlusal surfaces of the same tooth, benefits are limited to that of a multi-surface restoration. A separate benefit may be allowed for a non-contiguous restoration on the buccal or lingual surface(s) of the same tooth. Examples:

· In the event an anterior proximal restoration involves a significant portion of the labial or lingual surface, it may be reported as D2331 or D2332, as appropriate. · Any restoration involving two or more contiguous surfaces should be reported using the appropriate multiple surface restoration code. D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surface, primary or permanent D2160 Amalgam -three surface, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent RESIN-BASED COMPOSITE RESTORATIONS - DIRECT Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases and curing are included as part of the restoration. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, they should be reported separately (see D2951).

Resin restorations include base, pulp cap, acid-etch, bonding and polishing. Benefits for the replacement of an existing restoration are not payable to the same dentist if done within 24 months of the original restoration. The fee is not billable to the patient by the same participating dentist; denied for same non-participating dentist; paid if different dentist. Any restoration that involves the replacement of a surface previously restored within 24 months will be adjusted to pay only the new surface involved. Gingivectomies done on the same day as a restoration are considered part of the procedure and a separate charge may not be made to the patient by a participating dentist. ** Benefits for composite resin restorations on permanent (not including the buccal surface) or primary and permanent molars will be based on the corresponding benefit for an amalgam restoration. The patient is responsible for

include the buccal surface are covered.) General Policy - In the event an anterior proximal restoration involves a significant portion of the labial or lingual surface, it may be reported as D2331 or D2332, as appropriate, otherwise treat as D2330. D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior

Delta Dental Utilization Review Guidelines Page 26 1/1/21 D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based CDT: Incisal angle to be defined as one of the angles formed by the junction of the incisal and the mesial or distal surface composite - four or of an anterior tooth. more surfaces or involving incisal angle (anterior)

copy of the treatment chart. If the documentation suggests the patient is a bruxer, deny the restorations for contractual reasons. D2390 Resin-based CDT: Full resin-based composite coverage of tooth. composite crown, Code D2390-if performed on a primary anterior tooth, it is subject to a 24-month time limitation. anterior If code D2390 is performed on a permanent anterior tooth, it is considered a final crown restoration; and is subject to a 60-month time limitation. D2391 Resin-based CDT: Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive composite - one procedure. surface, posterior See ** above. D2392 Resin-based See ** above. composite - two Benefits should be administered with the same processing policies, system edits as code D2150, or paid as submitted. surface, posterior D2393 Resin-based See ** above. composite - three Benefits should be administered with the same processing policies, system edits as code D2160, or paid as submitted. surface, posterior D2394 Resin-based See ** above. composite -four or Benefits should be administered with the same processing policies, system edits as code D2161, or paid as submitted. more surfaces, posterior GOLD FOIL RESTORATIONS D2410 Gold-foil - one surface An alternate benefit will be allowed for an amalgam or resin restoration. Patient is responsible up to the dentists charge.

D2420 Gold-foil - two surfaces D2430 Gold-foil - three surfaces INLAY/ONLAY RESTORATIONS

not restore any cusp tips.

surfaces, but not the entire external surface. Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

Crowns and onlays are not a benefit for children under 12 years of age. This section includes cast inlays, onlays, restorative crowns and fixed bridges. Materials used can be cast in precious metals, semi-precious metals, non-precious metals, as well as porcelain. Cast restorations include all models, temporaries, final x-rays and other associated procedures.

Delta Dental Utilization Review Guidelines Page 27 1/1/21 NOTE: In some cases, an onlay is reported using both an inlay code and an onlay code. For example, a porcelain onlay on tooth #19 may be reported as tooth #19 code D2610 & tooth #19 code D2643. An onlay, by definition, includes the inlay.

claim using only the onlay code (D2643). Criteria for Onlays: Onlays (metallic and porcelain/ceramic) If the tooth does not meet the criteria for crown coverage, process as an alternate benefit of an amalgam restoration on posterior teeth, or as a composite restoration on anterior teeth. If tooth does meet the criteria for crown coverage, metallic onlay - approve; porcelain onlay - process as an alternate

Composite/Resin Onlays composite restoration on anterior teeth whether or not the tooth qualifies for full crown coverage. Patient is responsible

Limitation: ~~Payments for restorations (D2140-D2394,D2951) performed by the same dentist within 24 months of the placement of a crown/onlay/abutment will be deducted from the allowance for that major restorative procedure. (These restorations can be submitted as a core buildup.) ~~Administration of 60-Month Time Limitation: The general rule is that benefits for either one onlay or one crown per tooth will be allowed in a 60-month period. If an onlay were to be replaced with a single tooth crown within the 60- month time limitation, Delta Dental will make a payment of the difference between the current allowance for a crown and the amount Delta originally paid for the onlay. The patient is responsible for the balance up to the participating ­

~~A Gingivectomy performed on the same day as an onlay placement is considered part of the procedure and a separate charge may not be made to the patient. Inlays amalgam restoration. Porcelain/ceramic, composite/resin inlays will be benefited as an alternate benefit of an amalgam restoration on posterior teeth and as a composite restoration on anterior teeth. Patients are responsible for the

~~ If a buildup is submitted with an inlay, the buildup is wrapped up as part of the inlay procedure. Rationale:

acceptable treatment. Inlays do not protect teeth from cuspal fractures, therefore are no better than amalgams in that respect. If cuspal protection is not needed, amalgams will adequately restore the teeth. Delta Dental routinely reimburses the least costly benefit when more than one treatment modality can be used.

D2510 Inlay - metallic - one An alternate benefit allowance of an amalgam restoration will be made towards the cost of all metallic inlays. The patient surface D2520 Inlay - metallic - two surfaces D2530 Inlay - metallic - three or more surfaces

D2542 Onlay - metallic - two An allowance for a metallic onlay will be made only if the tooth meets the criteria for crown placement. Otherwise, an Tooth number, surfaces, surfaces alternate benefit allowance of an amalgam restoration will be made with the patient responsible for the difference up to and pre-operative the dentist's charge. periapical x-ray

Delta Dental Utilization Review Guidelines Page 28 1/1/21 D2543 Onlay - metallic - Tooth number, surfaces, three surfaces and pre-operative periapical x-ray

D2544 Onlay - metallic - four Tooth number, surfaces, or more surfaces and pre-operative periapical x-ray

D2610 Inlay - An alternate benefit allowance of an amalgam (posterior teeth)/composite (anterior teeth) restoration will be made porcelain/ceramic - one surface D2620 Inlay - porcelain/ceramic - two surfaces D2630 Inlay - porcelain/ceramic - three or more surfaces D2642 Onlay - A porcelain onlay is not a covered benefit under most subscriber contracts. An alternate benefit allowance of a metallic Tooth number, surfaces porcelain/ceramic - onlay will be made only if the tooth meets the criteria for crown coverage; if the tooth does not qualify for a crown, an and pre-op periapical x- two surfaces alternate benefit allowance of an amalgam (posterior teeth) /composite (anterior teeth) restoration will be made. In both ray

D2643 Onlay - If the subscriber has porcelain onlay coverage, yet the tooth does not qualify for a crown, an alternate benefit allowance Tooth number, surfaces porcelain/ceramic - of an amalgam (posterior teeth)/composite (anterior teeth) restoration will be made. The patient is responsible for the and pre-op periapical x- three surfaces ray D2644 Onlay - Tooth number, surfaces porcelain/ceramic - and pre-op periapical x- four or more surfaces ray D2650 Inlay - resin based An alternate benefit allowance of an amalgam restoration (posterior teeth)/composite restoration (anterior teeth) will be composite - one surface D2651 Inlay - resin based composite - two surfaces D2652 Inlay - resin based composite - three or more surfaces D2662 Onlay - resin based A composite/resin onlay is not a covered benefit. An alternate benefit allowance of an amalgam restoration (posterior composite - two teeth)/composite restoration (anterior teeth) will be made toward the cost of all composite onlays whether or not the surfaces

D2663 Onlay - resin based composite - three surfaces D2664 Onlay - resin based composite - four or more surfaces Criteria for Restorative Crowns

Delta Dental Utilization Review Guidelines Page 29 1/1/21 Cast restorations include all models, temporaries, laboratory fees and material, final radiographic images and other associated procedures. Gingivectomy, in conjunction with and for the purpose of placement of restorations/crowns, is included in the fee for the restoration; a separate charge may not be made to the patient. Exceptions: Allow a gingivectomy when performed on the same day as crown/onlay insertion if the tooth is broken below the gumline. A digital photograph is required. This policy pertains to crowns/onlays fabricated with Cerec.

Benefits are payable when the treatment is complete. For crowns, this is on the insertion/cementation date of the permanent crown, NOT the date of preparation. If a root canal appears to be inadequately filled, incomplete or unsuccessful in a tooth that is being treated with major restorative procedures, the same participating dentist who performed the root canal cannot not bill the patient; the procedure is denied for a non-participating or different dentist. If a root canal is performed after crown insertion, benefit a one surface restoration for endodontic access closure of a natural tooth. Attrition/Erosion/Abrasion/Abfraction/Corrosion and TMD Cases: Treatment to restore tooth structure lost due to attrition/erosion/abrasion/abfraction/corrosion and TMD is a contractual limitation and not a covered benefit. A Dental Consultant will review each case individually. Benefits for crowns will be made only for teeth that are in imminent danger of pulpal exposure radiographic images and any information provided by the treating dentist.

Criteria for Crown Coverage ~ Anterior teeth must exhibit at least two of the following: 1-The replacement of any existing restoration must be necessary due to caries, fracture, or missing tooth structure. 2-At least 50 percent of the incisal angle must require replacement due to decay or fracture. 3-There must be large existing restorations involving mesial and/or distal surfaces, encompassing at least 50% of tooth structure that require replacement due to decay or fracture. ~ Posterior teeth must exhibit one of the following: 1-Large area of decay on additional surface 2-Extensive recurrent decay 3-Must have a restoration encompassing at least two thirds of the occlusal surface leaving very thin buccal/lingual walls; as documented with photograph(s). 4-The existing restoration or caries must be within 2mm of the pulp radiographically OR Documentation must show more than half of the cusp missing (fractured off). Pre- operative radiographic image, clinical treatment notes and/or photograph are necessary for review. : Crowns for teeth with Cracked Tooth Syndrome will be considered on an I.C. basis. The patient's clinical treatment notes should document the following: 1-The date of onset of symptoms and follow-up reassessment appointments relating to the original diagnosis of cracked tooth syndrome (CTS). 2-Any conservative treatments attempted to make the tooth asymptomatic. This may include time monitoring the symptoms. 3-Sensitivity to cold and/or sensitivity to occlusal load. Other documentation necessary for review: 1-Pre-operative periapical radiographic image. 2-Pre-operative photograph(s) showing crack(s)/fracture lines. 3-If relevant, photograph(s) after removal of the existing restoration showing cuspal/pulpal fracture lines.

TEETH WITH MINIMAL OR NO RESTORATIONS REQUIRE TIME MONITORING: 2-4 WEEKS OR MORE.

Delta Dental Utilization Review Guidelines Page 30 1/1/21 Replacement: The subscriber's contract determines the time limitation for crown replacement. If the crown is replaced within the time limitation, the fee for the crown is the patient's responsibility. Upon appeal, the Consultant has two options: 1) Not billable to the patient - participating dentist (quality of care cases) o Open margin of the original crown o Open contact of the original crown o Insufficient crown length for proper retention of the original crown o Porcelain fracture within 3 months of original crown placement o RCT needed within 3 months of original crown placement 2) Deny o Recurrent decay when crown has properly fitting margins o Porcelain fracture after 3 months of crown placement o New crown needed because RCT needed after 3 months of crown placement o Patient unhappy with aesthetics of the original crown Periodontally Involved Tooth: As a guideline, any tooth that has only 50% or less of remaining bone should be

evaluation by a periodontist should be considered. Factors that should be taken into consideration include: the age of the patient, clinical findings such as pocket depths, mobility, the condition of the soft tissues, bone density, vertical vs. horizontal bone loss, the length of the roots and furcation involvement. If the supporting documentation is not sufficient to benefit the procedure, the Dental Consultant will deny the case.

A filling placed the same day as a crown on the same tooth is considered part of the procedure and is not billable to the patient by a participating dentist. If the dentist submits for a single surface filling after the crown is placed, pay for the filling. If the dentist submits for a multi-surface filling after the crown is placed, the fee is not billable to the patient by a participating dentist. CROWNS - Single Restorations Only Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

document and are contemporaneous. The only acceptable legal written documentation for utilization review are the contemporaneous treatment notes.

Crowns and onlays are not a benefit for children under 12 years of age. D2710 Tooth number and pre- composite (indirect) operative periapical x-ray

D2712 CDT: This procedure does not include facial veneers. Tooth number and pre- based composite operative periapical x-ray (indirect) D2720 Crown - resin with Tooth number and pre- high noble metal operative periapical x-ray

D2721 Crown - resin with Tooth number and pre- predominantly base operative periapical x-ray metal D2722 Crown - resin with Tooth number and pre- noble metal operative periapical x-ray

Delta Dental Utilization Review Guidelines Page 31 1/1/21 D2740 Crown - Tooth number and pre- porcelain/ceramic operative periapical x-ray

D2750 Crown - porcelain Tooth number and pre- fused to high noble operative periapical x-ray metal D2751 Crown - porcelain Tooth number and pre- fused to operative periapical x-ray predominately base metal D2752 Crown - -porcelain Tooth number and pre- fused to noble metal operative periapical x-ray

D2753 Crown - porcelain Tooth number and pre- fused to titanium and operative periapical x-ray titanium alloys D2780 Crown - 3/4 cast high Tooth number and pre- noble metal operative periapical x-ray

D2781 Crown - 3/4 cast Tooth number and pre- predominately base operative periapical x-ray metal D2782 Crown - 3/4 cast Tooth number and pre- noble metal operative periapical x-ray

D2783 Crown - 3/4 CDT: This procedure does not include facial veneers. Tooth number and pre- porcelain/ceramic operative periapical x-ray

D2790 Crown - full cast high Tooth number and pre- noble metal operative periapical x-ray

D2791 Crown - full cast Tooth number and pre- predominately base operative periapical x-ray metal D2792 Crown - full cast noble Tooth number and pre- metal operative periapical x-ray

D2794 Crown - titanium and Tooth number and pre- titanium alloys operative periapical x-ray

D2799 Provisional crown- CDT: Not to be used as a temporary crown for a routine prosthetic restoration. further treatment or completion of diagnosis necessary prior to final impression

Delta Dental Utilization Review Guidelines Page 32 1/1/21 1. Temporary (interim) or provisional restorations are not separate benefits and should be included in the fee for the permanent restoration. Benefits are not billable to the patient by a participating dentist. 2. When a temporary (interim) or provisional crown is billed as a therapeutic measure for a fractured tooth, benefits are denied. 3. Temporary or provisional fixed prostheses by the same dentist/dental office are not separate benefits and should be included in the fee for the permanent prosthesis. Fees are not billable to the patient by a participating dentist.

OTHER RESTORATIVE SERVICES Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

D2990 Resin infiltration of CDT: Placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the progression of the incipient smooth lesion. surface lesions DENIED unless covered by group/individual contract. D2910 Re-cement or re-bond a. Fees for the recementation or rebonding by the same dentist/dental office of covered restorations within six months inlay, onlay, or of initial placement are considered part of the fee for the original procedure and are not billable to the patient by a partial coverage participating dentist. restoration b. Benefit for one recementation or rebonding after six months have elapsed since initial placement. Recementations or rebonding in excess of one recementation by the same dentist/dental office are DENIED.

D2915 Re-cement or re-bond a. Fees for the recementation or rebonding by the same dentist/dental office of an indirectly fabricated or prefabricated indirectly fabricated post and core within six months of initial placement are considered part of the fee for the original procedure and are not or prefabricated post billable to the patient by a participating dentist. and core b. Benefits for recementation or rebonding after six months have elapsed since initial placement, but only once, to the same dentist/ dental office. Recementations or rebonding in excess of one recementation or rebonding by the same dentist/dental office are DENIED. c. Post recementation or rebonding (D2915) and crown recementation rebonding (D2920) are not allowed on the same tooth on the same day by the same dentist/dental office. The allowance will be made only for D2920 when D2915 and D2920 are submitted together. The fee for D2915 (Recement or rebonding indirectly fabricated or prefabricated post and core) are not billable to the patient by a participating dentist.

D2920 Re-cement or re-bond a. Fees for recementation or re-bonding of crowns are not billable to the patient by a participating dentist if done within crown six months of the initial seating date by the same dentist/dental office. b. Benefits may be paid for one recementation or re-bonding after six months have elapsed since the initial placement. Subsequent requests for recementation or re-bonding by the same dentist/dental office are DENIED. Benefits may be paid when billed by a dentist/dental office other than the one who seated the crown or performed the previous recementation or re-bonding.

D2921 Reattachment of No payment is made for the replacement of amalgam or composite restorations or attachment of a tooth fragment tooth fragment, incisal within 24 months and the fees are not billable to the patient by a participating dentist if done by the same dentist/dental edge or cusp office. Benefits may be allowed if done by a different dentist. Special consideration may be given by report.

D2929 Prefabricated a. Provide alternate benefit of prefabricated stainless crown - primary tooth steel crown with resin window (D2933). porcelain/ceramic b. D2929 is benefited once per lifetime.

Delta Dental Utilization Review Guidelines Page 33 1/1/21 D2928 Prefabricated a. The fee for the replacement of a prefabricated porcelain/ceramic crown by the same dentist/dental office within 24 porcelain/ceramic months is included in the initial crown placement and is not billable to the patient by a participating dentist. b. Benefits for D2928 are DENIED if done by different dentist/dental office within 24 months. tooth

D2930 Prefabricated a. D2930 is benefited once per lifetime. stainless steel crown - b. The fee for replacement of a stainless steel crown by the same dentist/dental office within 24 months primary tooth is included in the initial crown placement and is not billable to the patient by a participating dentist.

D2931 Prefabricated The fee for the replacement of a stainless steel crown by the same dentist/dental office within 24 months is included in stainless steel crown - the initial crown placement and is not billable to the patient by a participating dentist. permanent tooth D2932 Prefabricated resin Allowed on primary anterior teeth once per tooth in a 24 month period. If submitted on a permanent tooth, the code crown should be converted to procedure code D2999 and processed as a temporary crown. D2933 Prefabricated CDT: Open-face stainless steel crown with aesthetic resin facing or veneer. stainless steel crown with resin window a. A prefabricated stainless steel crown with resin window is a benefit only on anterior primary teeth. If submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for prefabricated stainless steel crown - primary tooth (D2930) or prefabricated stainless steel crown - permanent tooth (D2931) is made. The difference between the allowance for the D2930 or D2931 and the approved amount for the D2933 is DENIED and chargeable to the patient. b. A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is not billable to the patient by a participating dentist. Replacement within 24 months of initial placement by a different dentist/dental office is DENIED and the approved amount is chargeable to the patient.

D2934 Prefabricated esthetic CDT: Stainless steel primary crown with exterior esthetic coating. coated stainless steel crown - primary tooth

a. A prefabricated esthetic coated stainless steel crown is a benefit only on anterior primary teeth. If submitted for a posterior primary tooth or for a permanent tooth, an alternate benefit allowance for prefabricated stainless steel crown - primary tooth (D2930) or prefabricated stainless steel crown - permanent tooth (D2931) is made. The difference between the allowance for the D2930 or D2931 and the approved amount for the D2934 is DENIED and chargeable to the patient. b. A fee for replacement of a stainless steel crown on a primary or permanent tooth by the same dentist/dental office within 24 months is included in the initial crown placement and is not billable to the patient by a participating dentist. Benefits for replacement within 24 months of initial placement by a different dentist/dental office are DENIED and the approved amount is chargeable to the patient.

D2940 Protective restoration CDT: Direct placement of a restorative material to protect tooth and/or tissue form. This procedure may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used for endodontic access closure, or as a base or liner under a restoration. A protective restoration is a benefit as long as no other definitive treatment (i.e.: filling, RCT) is rendered to the tooth on the same date. Subject to 60 month time limitation; deny within that time period.

Delta Dental Utilization Review Guidelines Page 34 1/1/21 a. Protective restorations are covered benefits for emergency relief of pain. The fee for a protective restoration filling is not billable to the patient by a participating dentist when performed in conjunction with a definitive restoration by the same dentist/dental office on the same date of service. b. Pulp cap - direct (excluding final restoration) (D3110) or pulp cap - indirect (excluding final restoration) (D3120) are not billable to the patient by a participating dentist when billed in conjunction with D2940. c. No payment is made for protective restorations and the fees are not billable to the patient by a participating dentist with any restorative codes D2000-D2999, codes (D6200 - D6699), D3220 - D3330, D3346-D3353, D3410 - D3450. D2941 Interim therapeutic CDT: Placement of an adhesive restorative material following caries by hand or other method for the management of . Not considered a definitive restoration. dentition 1. Allow once per primary tooth. 2. D2941 is not billable to the patient by a participating dentist when submitted by the same dentist/dental office in conjunction with definitive restoration within 24 months.

D2949 Restorative CDT: Placement of restorative material to yield a more ideal form, including elimination of undercuts. foundation for an indirect restoration This procedure is a component of the definitive indirect restoration. Fees are not billable to the patient by a participating dentist. D2950 Core buildup, CDT: Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal Tooth number and pre- including any pins restorative procedure. A core buildup is not a filler to eliminate any undercut, box form or concave irregularity in a operative periapical x-ray when required preparation. A core buildup is a benefit once per tooth in 60 months. Pins are not separately reimbursed. A core buildup only qualifies for benefits when it is necessary to retain a cast restoration due to extensive loss of tooth structure from caries or fracture. If the procedure does not qualify, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. If an endodontically treated anterior tooth does not qualify for a core buildup, an alternate benefit of a one surface lingual composite restoration, procedure code D2330, to repair the access opening will be benefited. Patient is

Substructures are only a benefit when necessary to retain an indirectly fabricated restoration due to extensive loss of tooth structure from caries or fracture. A material is placed in the tooth preparation for a crown when there is insufficient tooth strength and retention for the crown procedure. Otherwise, fees are not billable to the patient by a participating dentist. The procedure should not be reported when the procedure only involves a filler to eliminate any undercut, box form or concave irregularity in the preparation. No payment is made for core buildups and the fees are not billable to the patient by a participating dentist when performed in conjunction with inlays, ¾ crowns, onlays and those involving inlay, ¾ crown and onlay bridges. A participating dentist may not charge the patient for this service. A tooth does not automatically qualify for a core buildup even though it may qualify for a crown, no payment is made for the core buildup and the fee is not billable to the patient by a participating dentist in these instances.

If the crown and buildup are submitted on the same claim/pretreatment and both do not qualify; deny the crown. No payment will be made for the D2950 core buildup and the fee is not billable to the patient by a participating dentist.

A tooth may have a core buildup, followed by endodontic therapy and then require another core buildup - the 60-month time limitation will be waived. No payment will be made for a core buildup done within 12 months of a 4 or more surface restoration. The same participating dentist cannot bill the patient, and the procedure will be denied to a non- participating dentist, as long as root canal therapy was not performed in between.

Delta Dental Utilization Review Guidelines Page 35 1/1/21 Unless necessary as a crown repair for caries or fracture, payment will not be made for an amalgam or composite restoration placed within 24 month after a core buildup or post and core and the fee is not billable to the patient by a participating dentist. If a crown and a core buildup are submitted with the same date of service, no payment will be made for both procedures and the fees are not billable to the patient.by a participating dentist. Delta Dental will ask for the insertion date of crown. If the treatment notes indicate the buildup was performed on the same date of service as the crown, it is not considered acceptable treatment unless it is a Cerec restoration. A participating dentist cannot bill the patient for the core buildup/DENY - non-participating dentist. D2951 Pin retention - per Benefits for pin retention are allowed on a per tooth basis (regardless of the number of pins placed) only in conjunction tooth, in addition to with an amalgam or composite restoration. restoration D2952 Post and core in CDT: Post and core are custom fabricated as a single unit. Tooth number and post addition to crown, a. An indirectly fabricated post and core in addition to crown is payable only on an endodontically treated tooth. No operative endo periapical indirectly fabricated payment is made for post and cores and the fees are not billable to the patient when radiographs indicate an absence of x-ray endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. Unresolved radiolucencies, but should be evaluated based on the time since the completion of the endodontic services and co-joint signs and symptoms. b. An indirectly fabricated post and core is a benefit in anterior teeth only when there is insufficient tooth structure to support a cast restoration, otherwise an alternate benefit will be made of a one surface lingual composite restoration, procedure code D2330, to repair the access opening.

Unless necessary as a crown repair for caries or fracture, no payment is made for an amalgam or composite restoration following a core buildup or post and core and the fee is not billable to the patient by a participating dentist.

A post and core only qualifies for benefits when it is necessary to retain a cast restoration due to extensive loss of tooth structure from caries or fracture. If the procedure does not qualify, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. *If a post & core is benefited and the tooth subsequently requires endo retreatment, a new post & core will be allowed (60-month time limitation is waived). If a Consultant determines the endo prognosis remains unfavorable after endo treatment, no payment is made for the claim for the crown, post & core and/or buildup and the fee is not billable to the patient by a participating dentist/DENY- non-participating dentist. A post and core only qualifies for benefits when it is necessary to retain a cast restoration due to extensive loss of tooth structure from caries or fracture. If the procedure does not qualify, no payment is made and the fee is not billable to the patient by a participating dentist/DENY-non-participating dentist. D2953 Each additional CDT: To be used with D2952. Tooth number, post- indirectly fabricated Individual consideration may be given by report. operative endo periapical post - same tooth x-ray and narrative

D2954 Prefabricated post CDT: Core is built around a prefabricated post. This procedure includes the core material. Tooth number and post and core in addition operative endo periapical to crown x-ray

Delta Dental Utilization Review Guidelines Page 36 1/1/21 Tooth number and post operative endo periapical x-ray a. A prefabricated post and core in addition to crown is payable only on an endodontically treated tooth. No payment is made for a post and core and the fee is not billable to the patient by a participating dentist when radiographs indicate an absence of endodontic treatment, incompletely filled canal space, or unresolved pathology associated with the involved tooth. Unresolved radiolucencies may be a reason to not pay and the fee is not billable to the patient by a participating dentist, but should be evaluated based on the time since the completion of the endodontic services and co-joint signs and symptoms. b. A prefabricated post and core is a benefit in anterior teeth only when there is insufficient tooth structure to support a cast restoration, otherwise an alternate benefit will be made of a one surface lingual composite restoration, procedure code D2330, to repair the access opening.

A post and core only qualifies for benefits when it is necessary to retain a cast restoration due to extensive loss of tooth structure from caries or fracture. If the procedure does not qualify, no payment is made and the fee is not billable to the patient by a participating dentist/DENY-non-participating dentist. ~If a prefabricated post and core is submitted with the same date of service as a crown, no payment is made and the fee is not billable to the patient by a participating dentist for both procedures. Delta Dental will request the seat date.

Unless necessary as a crown repair for caries or fracture, no payment is made for an amalgam or composite restoration following a core buildup or post and core and the fee is not billable to the patient by a participating dentist.

D2955 Post removal The fee for post removal when the procedure is rendered by the same dentist/office rendering retreatment, is a component of the fee for the retreatment. No payment is made and the fee is not billable to the patient by a participating dentist.

D2957 Each additional CDT: To be used with D2954. Tooth number, post- prefabricated post - operative endo periapical same tooth x-ray and narrative

D2960 Labial veneers (resin CDT: Refers to labial/facial direct resin bonded veneers. laminate) - direct DENIED unless covered by group/individual contract.

D2961 Labial veneer (resin CDT: Refers to labial/facial indirect resin bonded veneers. laminate - indirect DENIED unless covered by group/individual contract.

D2962 Labial veneer CDT: Refers also to facial veneers that extend interproximally and/or cover the incisal edge. Porcelain/ceramic veneers Tooth number and pre- (porcelain laminate) - presently include all ceramic and porcelain veneers. operative periapical x-ray indirect Benefits may be allowed if the tooth qualifies for full crown coverage. No additional restorative procedures (including crowns) will be allowed for 60 months. If the tooth does not qualify for crown coverage, benefits are denied.

Rationale: Temporary crowns are used after a tooth is prepped and while awaiting the placement of the permanent crown. They are considered part of the procedure for the permanent crown and the charge is included in the fee for the permanent crown. A separate charge for a temporary crown is not allowed for a participating provider. No payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. Temporary Crown - 2 Different Dentists

Delta Dental Utilization Review Guidelines Page 37 1/1/21 If a patient does not return to the original dentist to have the permanent crown seated, an allowance for the temporary crown can be made. (However, an allowance is only applicable if the permanent crown met the criteria for coverage. If the tooth did not qualify, deny the temporary for the same reason). If the patient then goes to another dentist and the temporary has been paid in history, deduct the amount allowed for the temporary crown from the allowed amount of the permanent crown and the patient is responsible for the difference. If a permanent crown is placed within 5 years of the temporary, same deduction rule applies.

D2971 Additional procedures CDT: To be reported in addition to a crown code. to construct new DENIED unless covered by group/individual contract. crown under existing partial denture framework

D2975 Coping CDT: A thin covering of the coronal portion of a tooth, usually devoid of anatomic contour, that can be used as a definitive restoration. DENIED unless covered by group/individual contract.

D2980 Crown repair a. No payment is made for a crown repair completed on the same date of service as a new crown and the fees are not necessitated by billable to the patient by a participating dentist. restorative material b. No payment is made for a crown repair and the fees are not billable to the patient by a participating dentist within 24 failure months of the original restoration by the same dentist/dental office. c. Benefits for D2980 are DENIED within 24 months of the original restoration by different dentist/dental office. d. Fees for a crown repair are benefited once in a 60 month period or according to the group contract.

D2981 Inlay repair DENIED unless covered by group/individual contract. If covered: necessitated by a. No payment is made for an inlay repair completed on the same date of service as a new inlay and the fees are not restorative material billable to the patient by a participating dentist. failure b. No payment is made for an inlay repair and the fees are not billable to the patient by a participating dentist within 24 months of the original restoration by the same dentist/dental office. c. Benefits for D2981 are DENIED within 24 months of the original restoration by different dentist/dental office. d. Fees for an inlay repair are benefited once in a 60 month period or according to the group contract.

D2982 Onlay repair a. No payment is made for an onlay repair completed on the same date of service as a new onlay and the fees are not necessitated by billable to the patient by a participating dentist. restorative material b. No payment is made for an onlay repair and the fees are not billable to the patient by a participating dentist within 24 failure months of the original restoration by the same dentist/dental office. c. Benefits for D2982 are DENIED within 24 months of the original restoration by different dentist/dental office. d. Fees for an onlay repair are benefited once in a 60 month period or according to the group contract.

D2983 Veneer repair a. No payment is made for a veneer repair completed on the same date of service as a new veneer and the fees are not necessitated by billable to the patient by a participating dentist. restorative material b. No payment is made for a veneer repair and the fees are not billable to the patient by a participating dentist within 24 failure months of the original restoration by the same dentist/dental office. c. Benefits for D2983 are DENIED within 24 months of the original restoration by different dentist/dental office. d. Fees for a veneer repair are benefited once in a 60 month period or according to the group contract.

Delta Dental Utilization Review Guidelines Page 38 1/1/21 D2999 Unspecified CDT: Use for a procedure that is not adequately described by a code. Describe procedure. Narrative restorative procedure, by report

May require IC review by Dental Consultant. If a patient goes to a lab for shade enhancement, the lab charges the dentist for a custom shade. The dentist can submit

denied. The dentist is allowed to charge the patient. MISCELLANEOUS RESTORATIVE Multi stage procedures are reported when completed. The completion date for crowns, onlays, bridges is the cementation date, regardless of the type of cement utilized.

Porcelain Butt Joints are not a covered benefit. A crown on a retained deciduous tooth is allowed as long as it has no successor and has sufficient periodontal support, i.e., no root resorption. The retained deciduous tooth must meet the criteria for a crown. Crowns for peg laterals are a benefit only if they meet the criteria for a crown. Restoring Occlusion: Procedures, appliances or restorations that are necessary to increase vertical dimension, restore occlusion or replace tooth structure lost by attrition, erosion, abrasion, abfraction, corrosion and TMD are contractually excluded. Other procedures for correcting congenital or developmental defects placed for esthetic purposes are contractually excluded and not reimbursable by Delta. If performed, the patient is responsible for the cost.

A crown on a supra-erupted tooth is not a benefit if being performed to bring an extruded tooth into the proper plane of occlusion. This is a contractual limitation, (i.e., altering, restoring or maintaining occlusion). It is only benefited if the tooth qualifies for a crown Crowns for Hemisectioned Teeth: Delta Dental allows only one crown per tooth. The fact that a tooth has been hemisected does not change the policy. The patient will be responsible for the additional crown. Teeth Splinted with Crowns (Rather than extracting the teeth and placing a fixed bridge - periodontally involved teeth) is not a covered benefit. ENDODONTICS (D3000-D3999) **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.**

dentist.

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

conventional methods are adequate. D3110 Pulp cap - direct CDT: Procedure in which the exposed pulp is covered with a dressing or cement that protects the pulp and promotes (excluding final healing and repair. restoration) Fees for a pulp cap performed in conjunction with a restoration by the same dentist/dental office are not billable to the patient by a participating dentist. D3120 Pulp cap - indirect CDT: Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from (excluding final additional injury and to promote healing and repair via formation of secondary dentin. This code is not to be used for restoration) bases and liners when all caries have been removed.

Delta Dental Utilization Review Guidelines Page 39 1/1/21 No payment is made for an indirect pulp cap performed in conjunction with a restoration by the same dentist/dental office and the fee is not billable to the patient by a participating dentist. The allowance for a final restoration includes pulp caps, cavity liners and cement bases. A separate fee may not be charged to the patient by a participating dentist /denied - non-participating dentist. PULPOTOMY D3220 Therapeutic CDT: Pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the vitality of the remaining pulpotomy (excluding portion by means of an adequate dressing. final restoration) - -To be performed on primary or permanent teeth removal of pulp -This is not to be construed as the first stage of root canal therapy coronal to the - Not to be used for apexogenesis dentinocemental junction and application of medicament

a. If provided on permanent teeth, process as palliative treatment (D9110) and any fees in excess of D9110 are not billable to the patient by a participating dentist.

are not billable to the patient by a participating dentist. D3221 Pulpal debridement, CDT: Pulpal debridement for the relief of acute pain prior to conventional root canal therapy. This procedure is not to be primary and used when endodontic treatment is completed on the same day. permanent teeth The relief of acute pain is benefited as gross pulpal debridement (D3221) for reimbursement purposes. It is not considered a separate procedure when performed by the same dentist/dental office on the same day the root canal is completed. D3222 Partial pulpotomy for CDT: Removal of a portion of the pulp and application of a medicament with the aim of maintaining the vitality of the apexogenesis - remaining portion to encourage continued physiological development and formation of the root. This procedure is not to permanent tooth with be construed as the first stage of root canal therapy. incomplete root development a. Benefits are based on group/individual contract. b. No payment is made for D3222 when performed within 30 days/same tooth/same dentist/dental office as root canal

ENDODONTIC THERAPY ON PRIMARY TEETH Endodontic therapy on primary teeth with succedaneous teeth and placement of resorbable filling. This includes pulpectomy, cleaning, and filling of canals with resorbable material.

D3230 Pulpal therapy CDT: Primary incisors and cuspids (resorbable filling) Root canal therapy on primary teeth is not a covered benefit unless there is no permanent successor. anterior, primary tooth (excluding final restoration)

D3240 Pulpal therapy CDT: Primary first and second molars (resorbable filling) posterior, primary tooth (excluding final restoration)

Delta Dental Utilization Review Guidelines Page 40 1/1/21 When a pulpectomy or pulpotomy are billed and radiographs reveal insufficient root structure, internal resorption, furcal perforation, or extensive periapical pathosis, the benefit for root canal therapy is DENIED. Root canal therapy on primary teeth is not a covered benefit unless there is no permanent successor. ENDODONTIC THERAPY (including Treatment Plan, Clinical Procedures and Follow-up Care) Includes primary teeth without succedaneous teeth and permanent teeth. Complete root canal therapy; pulpectomy is part of root canal therapy. Includes all appointments necessary to complete treatment; also includes intra-operative radiographic images. Does not include diagnostic evaluation and necessary radiographic images.

Benefits are payable on the completion date/final fill. A diagnostic radiographic image taken to ascertain the presence of pathology is a separate benefit. Procedure includes the pulp test, pulpotomy, palliative treatment, and all working and final treatment radiographic images when performed on the same date of service. Final restoration is not included. If root canal therapy is completed

per tooth basis. Palliative treatment in conjunction with root canal therapy by the same dentist/dental office on the same date of service is included in the fee for the root canal and is not separately billable. Any exam performed the same date of service as RCT is benefited for all dentists. When a patients coverage is for anterior root canals only, an allowance will be made for and molar canals. The

Benefits for root canals on teeth supporting an overdenture are only allowed if there is evidence of pathology.

A periodontally compromised tooth requiring endo will be benefited. A Dental Consultant may determine an adverse decision (no payment is made and the fees are not billable to the patient for a participating dentist) for the following reasons: - The fill is extremely short of the radiographic apex. - There is visible patent canal space left unfilled or has significant voids in the obturation of the canal. This fill may appear very poorly condensed (as if one accessory point were placed in the canal). - There is excessive over-extension of the filling material with obvious voids in the apical third of the canal. - Silver points were used with a very short fill or an overfill through the apices of the root. If a narrative is submitted with a reasonable explanation (i.e., calcified canal; unable to fill to apex, but tooth asymptomatic), the claim will be allowed. Each of these cases will require individual consideration. D3310 Endodontic therapy, If a dentist cannot complete a RCT and submits for payment, process as D3310, D3320 or D3330 and send to Consultant anterior tooth to assign fee. If the same dentist completes the RCT at a later date, deduct the amount allowed for the D3310, D3320 or (excluding final D3330 from the RCT allowance. If the RCT is completed by a different dentist, no deduction will be made. restoration) D3320 Endodontic therapy, If a dentist does not complete the RCT because the patient does not return in a timely manner for completion premolar tooth (approximately 3 months), process as a D3310, D3320 or D3330 and pay one half of the allowance. If the patient returns (excluding final to the same dentist for completion of the RCT, deduct the amount that was allowed for the D3310, D3320 or D3330 from restoration) the RCT allowance. D3330 Endodontic therapy, Root canals on deciduous teeth are not benefits. However, if there is no permanent successor, a root canal will be molar tooth allowed and benefited as either an anterior or premolar root canal based on the position of the tooth. Need post-op endo (excluding final PA for review. restoration) D3331 Treatment of root CDT: In lieu of surgery, the formation of a pathway to achieve an apical seal without surgical intervention because of a canal obstruction; non-negotiable root canal blocked by foreign bodies, including but not limited to separated instruments, broken posts or non­surgical access calcification of 50% or more of the length of the tooth root.

Delta Dental Utilization Review Guidelines Page 41 1/1/21 a. This procedure is considered a component of a root canal. A separate fee for the procedure by the same dentist/dental office is not billable to the patient by a participating dentist on same date of service as the root canal therapy. b. The fee for D2955, post removal, is not included as part of treatment of root canal obstruction.

D3332 Incomplete CDT: Considerable time is necessary to determine diagnosis and/or provide initial treatment before the fracture makes Pre-op and working endodontic therapy; the tooth unretainable. periapicals x-rays & inoperable, Not to be confused with an incomplete RCT (D3999). This code is to be used for a tooth that is inoperable, unrestorable narrative unrestorable or or fractured. Since the tooth is deemed unrestorable, no further treatment will be benefited (except for an extraction). fractured tooth Individual consideration may be given if an endodontist is able to successfully complete the root canal.

D3333 Internal root repair of CDT: Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by provider filing claim. perforation defects

a. Internal root repair is only a benefit on permanent teeth with incomplete root development or for repair of a perforation. b. If submitted on a primary tooth, benefits for D3333 are denied. c. If submitted on a permanent tooth, fees for D3333 are not billable to the patient by a participating dentist when submitted with on the same date of service. d. The procedure is accomplished by recalcification of the defect. In the event surgical intervention is performed by the same dentist/dental office, the fee for the procedure is not billable to the patient by a participating dentist in addition to apicoectomy and/or retrograde filling. Also, if reported on a primary tooth the benefits for internal root repair of perforation defects are denied as investigational. e. The fees for D3333 are not billable to the patient by a participating dentist if perforation is iatrogenic by the same dentist/dental office submitting the claim.

ENDODONTIC RETREATMENT General Policy - This procedure may include the removal of a post, pin(s), old root canal filling material, and the procedures necessary to prepare the canals and place the canal filling. This includes complete root canal therapy and separate fees for these procedures by the same dentist/dental office are not billable to the patient by a participating dentist 30 days prior to retreatment as included in the fees for the retreatment. Separate fees for these procedures by a different dentist/dental office are DENIED.

D3346 Retreatment of Retreatment of root canal therapy or retreatment of apical surgery by the same dentist/dental office within 24 months is Pre-op x-rays (for pre tx) previous root canal considered part of the original procedure. No payment is made for the retreatment by the same office and the fees are and pre and post op x-rays therapy - anterior not billable to the patient by a participating dentist. (for claim) This procedure may include the removal of a post, pin(s), old root canal filling material, and the procedures necessary to prepare the canals and place the canal filling. This includes complete root canal therapy. Separate fees for these procedures by the same dentist/dental office are not billable to the patient by a participating dentist 30 days prior to retreatment as they are included in the fees for the retreatment.

D3347 Retreatment of previous root canal therapy - premolar D3348 Retreatment of previous root canal therapy - molar /RECALCIFICATION

Delta Dental Utilization Review Guidelines Page 42 1/1/21 D3351 Apexification/recalcifi CDT: Includes opening tooth, preparation of canal spaces, first placement of medication and necessary radiographs. cation- initial visit (This procedure may include first phase of complete root canal therapy). (apical closure/calcific repair of perforations, root resorption, etc.)

Apexification is only benefited on permanent teeth with incomplete root development or for repair of a perforation. Procedures include all working and post-operative x-rays, bacteriologic cultures, local anesthesia and routine follow-up care. Any exam performed the same date of service as an apexification/recalcification is benefited for all dentists. A diagnostic radiographic image taken to ascertain the presence of pathology is a separate benefit.

D3352 Apexification/recalcifi CDT: For visits in which the intra-canal medication is replaced with new medication Includes any necessary radiographs. cation - interim Apexification treatment is allowed when radiographs show incomplete closure of the tooth apex, or the tooth is being medication treated for traumatic injuries; D3352 is not to exceed 3 visits prior to the root canal therapy. replacement D3353 Apexification/recalcifi CDT: Includes removal of intra-canal medication and procedures necessary to place final root canal filling material cation - final visit including necessary radiographs. (This procedure includes last phase of complete root canal therapy). (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) PULPAL REGENERATION D3355 Pulpal regeneration - CDT: Includes opening tooth, preparation of canal spaces, placement of medication. initial visit This procedure is considered experimental and benefits are DENIED. D3356 Pulpal regeneration - This procedure is considered experimental and benefits are DENIED. interim medication replacement D3357 Pulpal regeneration - CDT: Does not include final restoration. completion of This procedure is considered experimental and benefits are DENIED. treatment APICOECTOMY/PERIRADICULAR SERVICES **See Benefit Check for contract specific information regarding medical prime procedures. is a term used to describe surgery to the root surface (i.e., apicoectomy), repair of a root perforation or resorptive defect, exploratory curettage to look for root fractures, removal of extruded filling materials or instruments, removal of broken root fragments, sealing of accessory canals, etc. This does not include retrograde filling material placement. Apicoectomy/Periradicular Services (D3410-D3470, D3920) General Policy - No payment is made for biopsy (D7285, D7286), frenulectomy (D7961, D7962) and excision of hard and soft tissue lesions (D7410, D7411, D7450, D7451) and the fees are not billable to the patient by a participating dentist when the procedures are performed on the same date, same surgical site/area, by the same dentist/dental office as the above referenced codes. Requests for individual consideration may be submitted by report for dental consultant review.

D3410 ** CDT: For surgery on root of anterior tooth. Does not include placement of retrograde filling material. anterior

Delta Dental Utilization Review Guidelines Page 43 1/1/21 ** anterior Procedures include all working and post-operative x-rays, bacteriologic cultures, local anesthesia and routine follow-up care. Retreatment by the same dentist/dental office within 24 months is considered part of the original procedure and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. Any exam performed the same date of service as an apicoectomy is benefited for all dentists. A diagnostic radiographic image taken to ascertain the presence of pathology is a separate benefit. D3421 ** CDT: For surgery on one root of a premolar. Does not include placement of retrograde filling material. If more than one premolar (first root) root is treated, see procedure code D3426. D3425 ** CDT: For surgery on one root of a molar. Does not include placement of retrograde filling material. If more than one root (first root) is treated, see procedure D3426. D3426 **Apicoectomy CDT: Typically used for premolar and molar surgeries when more than one root is treated during the same procedure. This does not include retrograde filling material placement. (each additional root)

D3471 Surgical repair of root CDT: For surgery on root of anterior tooth. Does not include placement of restoration. resorption - anterior

Fees for surgical repair of root resorption are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333, D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3472 Surgical repair of root CDT: For surgery on root of premolar tooth. Does not include placement of restoration.

Fees for surgical repair of root resorption are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333 D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3473 Surgical repair of root CDT: For surgery on root of molar tooth. Does not include placement of restoration.

Fees for surgical repair of root resorption are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333 D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3501 Surgical exposure of CDT: Exposure of root surface followed by observation and surgical closure of the exposed area. Not to be used for or in root surface without conjunction with apicoectomy or repair of root resorption. apicoectomy or repair

anterior Fees for surgical exposure of root surface are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333 D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3502 Surgical exposure of CDT: Exposure of root surface followed by observation and surgical closure of the exposed area. Not to be used for or in root surface without conjunction with apicoectomy or repair of root resorption. apicoectomy or repair

premolar

Delta Dental Utilization Review Guidelines Page 44 1/1/21 Fees for surgical exposure of root surface are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333 D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3503 Surgical exposure of CDT: Exposure of root surface followed by observation and surgical closure of the exposed area. Not to be used for or in root surface without conjunction with apicoectomy or repair of root resorption. apicoectomy or repair

molar Fees for surgical exposure of root surface are not billable to the patient by a participating dentist when performed on the same tooth by the same dentist/dental office on the same date as D3333 D3410-D3426, D3430, D3450, D4210- D4212, D4231, D4240, D4241, D4245, D4249, D4260, D4261, D4268, D4270, D4273-D4278, D4283 and D4285.

D3428 **Bone graft in CDT: Includes non-autogenous graft material. conjunction with these procedures when billed in conjunction with periradicular surgery are DENIED as specialized technique. per tooth, single site

D3429 **Bone graft in CDT: Includes non-autogenous graft material. conjunction with these procedures when billed in conjunction with periradicular surgery are DENIED as specialized technique. each additional contiguous tooth in the same surgical site

D3430 Retrograde filling - CDT: For placement of retrograde filling material during periradicular surgery procedures. If more than one filling is per root placed in one root - report as D3999 and describe. If more than one root is filled in a tooth, list each retrograde filling separately. ~ Allow 1 retro grade filling per anterior tooth. For each additional root, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. ~ Allow 2 retro grade fillings per premolar. For each additional root, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. ~ Allow 3 retro grade fillings per molar tooth. For each additional root, no payment is made and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. D3431 Biologic materials to Benefits are available only when billed for natural teeth. Benefits for these procedures when billed in conjunction with aid in soft and periradicular surgery, etc. are DENIED as a specialized technique. osseous tissue regeneration in conjunction with periradicular surgery D3432 Guided tissue Benefits are available only when billed for natural teeth. Benefits for these procedures when billed in conjunction with regeneration, periradicular surgery are DENIED as a specialized technique. resorbable barrier, per site, in conjunction with periradicular surgery D3450 Root amputation - per CDT: of a multi-rooted tooth while leaving the crown. If the crown is sectioned, see D3920. root Root amputation involves the removal of a root of a multi-rooted tooth without the removal of the corresponding portion of the crown.

Delta Dental Utilization Review Guidelines Page 45 1/1/21 If a claim is submitted for a root amp for a single rooted tooth, the procedure is considered and benefited as a D7210 surgical extraction. This may occur with any tooth, but is more likely to occur with an anterior or premolar tooth.

Root amputation is indicated for:

b) An untreatable infrabony defect of one root of a multi-rooted tooth c) Fractures extending into furcation d) Teeth where non-surgical endodontic treatment is not possible or unsuccessful for at least one root and periapical surgery is not possible into the furcation e) Teeth where a exists and is confined to the root, which is to be separated and extracted f) Chronic periapical pathology g) Cases of persistent sinus tract, periradicular , or periradicular pathosis where non-surgical root canal therapy or periradicular surgery is not possible. h) Inoperable or uncorrectable resorptive defects of the root. Root amputation necessitates of all remaining roots. D3460 Endodontic CDT: Placement of implant material, which extends from a pulpal space into the bone beyond the end of the root. endosseous implant DENIED unless covered by group/individual contract. D3470 Intentional CDT: For the intentional removal, inspection and treatment of the root and replacement of a tooth into its own socket. reimplantation This does not include necessary retrograde filling material placement. (including necessary DENIED unless covered by group/individual contract. splinting) OTHER ENDODONTIC PROCEDURES D3910 Surgical procedure for The fee for isolation with a rubber dam is included in the fee for the entire endodontic procedure. isolation of tooth with rubber dam

D3920 Hemisection CDT: Includes separation of a multi-rooted tooth into separate sections containing the root and the overlying portion of (including any root the crown. It may also include the removal of one or more of those sections. removal), not including root canal therapy Any pontic space created by a hemisected tooth is considered beyond the normal complement of natural teeth and is a special condition of that patient's mouth. The patient must be responsible for the cost necessary to replace such teeth

Loss of a supernumerary tooth; b) Space created by a hemisection of a multi-rooted tooth. c) space created from orthodontic movement. D3950 Canal preparation and fitting of preformed dowel or post

D3999 Unspecified CDT: Used for an endodontic procedure that is not adequately described by a code. Describe procedure. Narrative endodontic May require IC review by Dental Consultant. procedure, by report PERIODONTICS D4000-D4999 **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.** Codes covered if the subscriber's contract has Enhanced Periodontal and Implant Riders: D4263, D4264, D4266, D4267, D7953

Delta Dental Utilization Review Guidelines Page 46 1/1/21 Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist. Required Periodontal Charting: ~ Must be dated and include the patient's name. ~ Current periodontal charting taken (no more than 12 months old) w/4-6 probing depths per tooth General Policy- Periodontal charting is considered as part of an oral evaluation (D0120, D0150, D0160, D0180). If periodontal evaluation and an oral evaluation are billed on the same date of service, the fee for the oral evaluation (D0120, D0150, D0160) is a benefit. No payment is made for the periodontal evaluation (D0180) and the fee is not billable to the patient by a participating dentist.

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

document and are contemporaneous. The only acceptable legal written documentation for utilization review are the contemporaneous treatment notes. General policy for all periodontal surgical procedures - Periodontal surgical procedures include all necessary postoperative care, finishing procedures and evaluations for three months, surgical re-entry for 36 months. When a surgical procedure is billed within three months of the initial surgical procedure in relation to both natural teeth and implants by the same dentist/dental office, no payment is made for the surgery and the fee is not billable to the patient by a participating dentist. In the absence of documentation of extraordinary circumstances, no payment is made for additional surgery by the same dentist/dental office for 36 months and the fee is not billable to the patient by a participating dentist. If extraordinary circumstances are present, the benefits will be DENIED and are chargeable to the patient up to the approved amount for the surgery. General policy - Providing more than two D4265, D4266, D4267 (osseous and guided tissue regeneration), D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285 (tissue grafts) or D4263, D4264, D6103, D6104 and D7953 (osseous grafts) within any given quadrant is highly unusual and additional submissions should only be considered on a by report basis. Fees for anything more than two sites (teeth) in a quadrant are DENIED.

The term specialized procedure describes a dental service or procedure that is used when unusual or extraordinary circumstances exist and is not generally used when conventional methods are adequate. General Policy for Periodontal surgical services (D4210-4285) No payment will be made for biopsy (D7285, D7286), frenulectomy (D7961, D7962) and excision of hard and soft tissue lesions (D7410, D7411, D7450, D7451) and the fees are not billable to the patient by a participating dentist when the procedures are performed on the same date, same surgical site/area, by the same dentist/dental office as the above referenced codes. DENY if on different date. Requests for individual consideration can always be submitted by report for dental consultant review and approve if there is a rationale to separating the procedures. Mucogingival grafts are DENIED on the same date of service as D4210, D4211, D4240, D4241, D4260 and D4261 in the same quadrant. Periodontal procedures related to implant placement and maintenance are typically adjudicated using the implant code section. SURGICAL SERVICES (Including Usual Postoperative Care) CDT Definition: Site: soft tissue recession on a single tooth or an osseous defect adjacent to a single tooth; also used to indicate soft tissue defects and/or osseous defects in edentulous tooth positions. · If two contiguous teeth have areas of soft tissue recession, each tooth is a single site. · If two contiguous teeth have adjacent but separate osseous defects, each defect is a single site. · If two contiguous teeth have a communicating interproximal osseous defect, it should be considered a single site.

· All non-communicating osseous defects are single sites. · All edentulous non-contiguous tooth positions are single sites. · Up to two contiguous edentulous tooth positions may be considered a single site. Tooth Bounded Space: A space created by one or more missing teeth that has a tooth on each side.

Delta Dental Utilization Review Guidelines Page 47 1/1/21 D4210 Gingivectomy or CDT: It is performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or Quadrant or tooth four or asymmetrical or unaesthetic topography is evident with normal bony configuration. numbers, current more contiguous periodontal charting (no teeth or tooth Count tooth bounded spaces for that includes a flap procedure (D4240, D4260). Do not count more than 12 months old) bounded spaces per tooth bounded spaces for D4210, D4211, D4341, D4342; count only "diseased teeth/." A tooth bounded w/4-6 probing depths per quadrant space counts as one space irrespective of the number of teeth that would normally exist in the space. tooth or narrative describing condition of the tissue Benefit only two full quadrants of surgery on the same date of service. Additional documentation, including a treatment chart and explanation of treatment plan, are required when more than two quadrants are done on the same day. No payment is made and the fee is not billable to the patient by a participating dentist. D4211 Gingivectomy or CDT: It is performed to eliminate suprabony pockets or to restore normal architecture when gingival enlargements or Quadrant or tooth asymmetrical or unaesthetic topography is evident with normal bony configuration. numbers, current three contiguous involving soft tissue only is appropriately coded as D4211. See D4210 descriptor. periodontal charting (no teeth or tooth more than 12 months old) bounded spaces per w/4-6 probing depths per quadrant tooth or narrative describing condition of the tissue

No payment is made for any surgical re-entry in the same quadrant within 3 months and the fee is not billable to the patient by a participating dentist. From 4 to 24 months any re­entry is denied. Surgical re-entry includes gingivectomy (D4210 or D4211) and osseous surgery (D4260).

Gingivectomy, when submitted with the same date of service as osseous surgery (D4260), is considered part of the osseous surgery and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist.

*Gingivectomy performed around an implant may be approved if a narrative indicates hyperplastic tissue. Removal of hyperplastic tissue with a laser for orthodontic reasons is a gingivectomy D4211 and may be billed separately. Claim must be accompanied by a narrative, periodontal charting and photo(s) for benefit determination. A gingivectomy performed prior to or in conjunction with the placement of orthodontic brackets is eligible for coverage only if the tooth is fully erupted and has gingival hyperplasia. A gingivectomy is not covered when performed to facilitate bracket placement on partially erupted teeth to accelerate the orthodontic case.

D4212 Gingivectomy or When performed on the same date as the preparation of a crown or other restoration it is included in the fee for the Narrative gingivoplasty to allow restoration, and separate fees are not billable to the patient by the same dentist/dental office. access for restorative procedure, per tooth

D4230 Anatomical crown CDT: This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and exposure - four or supporting bone (ostectomy) to provide an anatomically correct gingival relationship. more contiguous Not a covered benefit. This procedure is considered primarily cosmetic in nature. If this procedure is being done because teeth or tooth of decay or fracture, the proper code to use is D4249. bounded spaces per quadrant D4231 Anatomical crown CDT: This procedure is utilized in an otherwise periodontally healthy area to remove enlarged gingival tissue and exposure - one to supporting bone (ostectomy) to provide an anatomically correct gingival relationship. three teeth or tooth Not a covered benefit. This procedure is considered primarily cosmetic in nature. If this procedure is being done because bounded spaces per of decay or fracture, the proper code to use is D4249. quadrant

Delta Dental Utilization Review Guidelines Page 48 1/1/21 D4240 Gingival flap CDT: A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation FMX; complete current procedure, including tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, periodontal charting (no root planing - four or reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed more than 12 months old) more contiguous in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased teeth or tooth access to the root surface and alveolar bone, or to determine the presence of a cracked tooth, fractured root or external bounded spaces per root resorption. Other procedures may be required concurrent to D4240 and should be reported separately using their quadrant own unique codes.

Benefit only two full quadrants of flap surgery on the same date of service. Additional documentation, including a treatment chart and explanation of treatment plan, are required when more than two quadrants are done on the same day. No payment is made for additional quadrants and the fees are not billable to the patient by a participating dentist.

D4241 Gingival flap CDT: A soft tissue flap is reflected or resected to allow debridement of the root surface and the removal of granulation FMX; complete current procedure, including tissue. Osseous recontouring is not accomplished in conjunction with this procedure. May include open flap curettage, periodontal charting (no root planing - one to reverse bevel flap surgery, modified Kirkland flap procedure, and modified Widman surgery. This procedure is performed more than 12 months old) three contiguous in the presence of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for increased teeth or tooth access to the root surface and alveolar bone, or to determine the presence of a cracked tooth, fractured root or external bounded spaces per root resorption. Other procedures may be required concurrent to D4241 and should be reported separately using their quadrant own unique codes.

When done on the same date of service as osseous surgery, and it is in the same surgical site, this procedure is considered part of the osseous surgery and the fee is not billable to the patient by a participating dentist/DENY - non- participating dentist. In order to qualify for benefits the following conditions must exist: 1. Probing depths must be 5mm or greater. 2. Radiographs must show attachment loss with the appearance of reduction of the alveolar crest beyond the 1 -1 1/2mm proximity to the cemento-enamel junction (CEJ). This procedure facilitates access via resection and retraction of a soft tissue flap. By definition, procedure D4241 includes root planing and therefore would not precede or follow nonsurgical root planing in the same episode of treatment. Count teeth bounded spaces for pocket reduction surgery that includes a flap procedure (D4240, D4241, D4260, D4261). Do not count tooth bounded teeth for D4210, D4211, D4341, D4342; count only "diseased natural teeth/periodontium." A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space.

D4245 Apically positioned CDT: Procedure is used to preserve keratinized gingival in conjunction with osseous resection and second stage implant FMX; complete current flap procedure. Procedure may also be used to preserve keratinized/attached gingival during surgical exposure of labially periodontal charting (no impacted teeth, and may be used during treatment of peri-implantitis. more than 12 months old) *Same criteria and administration as procedure D4240. D4249 Clinical crown CDT: This procedure is employed to allow a restorative procedure on a tooth with little or no tooth structure exposed to Tooth number, current pre- lengthening - hard the oral cavity. Crown lengthening requires reflection of a full thickness flap and removal of bone, altering the crown to operative periapical x-rays tissue, by report root ratio. It is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed in and a narrative the presence of periodontal disease.

This procedure is subject to a 60-month time limitation. Crown lengthening will be considered only when a crown or deep subgingival restoration is indicated.

Delta Dental Utilization Review Guidelines Page 49 1/1/21 Rationale: Crown lengthening is payable per site and not payable per tooth when adjacent teeth are included. This procedure is carried out to expose sound tooth structure by removal of bone before restorative or prosthodontic procedures. It is not generally provided in the presence of periodontal disease. Sufficient healing time is required prior to final restoration. This procedure is a benefit only when bone is removed and sufficient time is allowed for healing.

Crown lengthening (D4249) performed on the same date of service in conjunction with free soft tissue graft procedures (D4277, D4278) or osseous surgery (D4260) in the same quadrant should not exceed the reimbursement for one

allowance should not exceed that of a full quadrant of osseous surgery. If D4249 is performed on the same date of service as restoration placement, fees for D4249 are not billable to the patient by a participating dentist. No payment is made for crown lengthening performed on the same date of service or within 14 days of a crown cementation and the fee is not billable to the patient by a participating dentist. D4260 Osseous surgery CDT: This procedure modifies the bony support of the teeth by reshaping the to achieve a more FMX; complete current (including elevation of physiologic form during the surgical procedure. This must include the removal of supporting bone (ostectomy) and/or periodontal charting (no a full thickness flap non-supporting bone (osteoplasty). Other procedures may be required concurrent to D4260 and should be reported more than 12 months old) and closure ) - four or using their own unique codes. more contiguous Osseous surgery is performed in the presence of periodontal disease. The procedure is designed to modify and reshape teeth or tooth deformities in the alveolar bone surrounding the teeth and to reduce pocket depths. bounded spaces per Rationale: 1. This procedure modifies and reshapes deformities in the alveolar bone surrounding teeth. This service is commonly provided when treating more involved periodontitis. For dental benefit reporting purposes, a quadrant is defined as four or more contiguous teeth and or teeth bounded space, per quadrant. Count only teeth with loss of attachment. 2. The purpose of osseous surgery (D4260) is to eliminate the pockets by means of eradication or new attachment. The implication in this procedure is that having made a flap entry, the dentist will complete all procedures necessary to achieve that purpose.

Benefit only two full quadrants of osseous surgery on the same date of service. Additional documentation, including a treatment chart and explanation of treatment plan, are required when more than two quadrants are done on the same day. No payment is made for additional quadrants the fees are not billable to the patient by a participating dentist.

D4261 Osseous surgery CDT: This procedure modifies the bony support of the teeth by reshaping the alveolar process to achieve a more FMX; complete current (including elevation of physiologic form during the surgical procedure. This must include the removal of supporting bone (ostectomy) and/or periodontal charting (no a full thickness flap non-supporting bone (osteoplasty). Other procedures may be required concurrent to D4261 and should be reported more than 12 months old) and closure ) - one to using their own unique codes. three teeth or bounded teeth spaces per quadrant The fee for osseous surgery includes: Osseous contouring, distal or proximal wedge surgery; frenectomy; curettage or ; soft tissue grafts; gingivectomy; flap procedures. These procedures are considered part of the osseous surgery and the fee is not billable to the patient by a participating dentist/DENY - non-participating dentist. When crown lengthening is done in the same surgical site and on the same date of service as osseous, the total reimbursement for both procedures should not exceed the reimbursement for one full quadrant of osseous surgery.

Separate benefits may be available for: bone replacement grafts, soft tissue grafts, guided tissue regeneration, biologic materials with demonstrated efficacy in aiding periodontal tissue regeneration, exostosis removal, hemisection, extraction, apicoectomy and root amputations. A healing period of at least 14 days should be allowed after scaling and root planing (D4341) before osseous surgery can be performed.

Delta Dental Utilization Review Guidelines Page 50 1/1/21 If there is a combination of procedures in one quadrant (i.e., buccal flap procedure, gingivectomy on lingual surfaces, etc.), then the greater procedure (D4260) is benefited. In order to qualify for benefits the following conditions must exist: 1. Probing depths must be 5mm or greater. 2. Radiographs must show attachment loss with the appearance of reduction of the alveolar crest beyond the 1 - 1 1/2 mm proximity to the cemento-enamel junction (CEJ). A full quadrant code D4260 is used when 4 or more teeth are treated in a quadrant. If 1-3 teeth are treated, use partial quadrant code D4261. Count tooth bounded spaces for pocket reduction surgery that includes a flap procedure (D4240, D4260). Do not count tooth bounded spaces for D4210, D4211, D4341, D4342; count only "diseased teeth/periodontium." A tooth bounded space counts as one space irrespective of the number of teeth that would normally exist in the space.

Rationale: 1. There is no need to count teeth that are not diseased and do not otherwise require the treatment being

2. Current processing policies provide rationale for definition of diseased teeth. 3. Counting teeth bounded spaces accounts for flap extension. 4. Tooth bounded space: A space created by one or more missing teeth that has a tooth on each side.

If no teeth in the quadrant qualify, Dental Consultant will deny. D4263 Bone replacement CDT: This procedure involves the use of grafts to stimulate periodontal regeneration when the disease process has led to graft - first site in a deformity of the bone. This procedure does not include flap entry and closure, wound debridement, osseous quadrant contouring or the placement of biologic materials to aid in osseous tissue regeneration or barrier membranes. Other separate procedures delivered concurrently are documented with their own codes. Not to be reported for an edentulous space or an extraction site. Allowed if the subscriber has the Enhanced Periodontal and Implant Rider. Subject to 24 month time limitation.

D4264 Bone replacement CDT: This procedure involves the use of grafts to stimulate periodontal regeneration when the disease process has led to graft-each additional a deformity of the bone. This procedure does not include flap entry and closure, wound debridement, osseous site in quadrant contouring or the placement of biologic materials to aid in osseous tissue regeneration or barrier membranes. This procedure is performed concurrently with one or more bone replacement grafts to document the number of sites involved. Not to be reported for an edentulous space or an extraction site. Subject to 24 month time limitation. D4263 & D4264 are not covered benefits unless specified under the subscriber's contract. Osseous grafts are limited to periodontal deformities due to the disease process and are considered regenerative techniques. The procedure is limited to a 24-month time limitation. D4265 Biologic materials to CDT: Biologic materials may be used alone or with other regenerative substrates such as bone and barrier membranes, aid in soft and depending upon their formulation and the presentation of the periodontal defect. This procedure does not include osseous tissue surgical entry and closure, wound debridement, osseous contouring, or the placement of graft materials and/or barrier regeneration membranes. Other separate procedures may be required concurrent to D4265 and should be reported using their own unique codes. DENIED unless covered by group/individual contract. If covered: a. Benefits are available only when billed for natural teeth. b. Biologic materials may be a benefit when reported with periodontal flap surgery(D4240, D4241, D4245, D4260, and D4261). c. Benefit one D4265 per tooth, per 36 months. d. When submitted with a D4263, D4264, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4341 or D4342 in the same surgical site, the benefit for the D4265 is DENIED. e. Benefit for these procedures when billed in conjunction with implants, or other oral surgical procedures are DENIED as a specialized procedure.

Delta Dental Utilization Review Guidelines Page 51 1/1/21 D4266 Guided tissue CDT: This procedure does not include flap entry and closure, or, when indicated, wound debridement, osseous regeneration­ contouring, bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure resorbable barrier, per can be used for periodontal and peri-implant defects. site a. When submitted with D4260 or D4266 should be considered for separate benefits. b. Benefits are available only when billed for natural teeth. Benefits for these procedures when billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc. are DENIED as a specialized or elective technique. c. When submitted with a D4263, D4264, D4266, D4270, D4273, or D4275 in the same surgical site, the fee for the D4267 is DENIED. Allow for separate payment of biologic materials (membranes, bone) under D4263, D4265, D4266, D4267 in conjunction with flap for surgical entry D4240, D4241, D4260, D4261.

The procedure is limited to a 24 month time limitation. D4267 Guided tissue CDT: This procedure does not include flap entry or closure, or, when indicated, wound debridement, osseous contouring, regeneration - non- bone replacement grafts, and placement of biologic materials to aid in osseous regeneration. This procedure can be resorbable barrier, per used for periodontal and peri-implant defects. site (includes membrane removal) Same guideline as D4266. D4268 Surgical revision CDT: This procedure is to refine the results of a previously provided surgical procedure. This may require a surgical procedure, per tooth procedure to modify the irregular contours of hard or soft tissue. A mucoperiosteal flap may be elevated to allow access to reshape alveolar bone. The flaps are replaced or repositioned and sutured. D4270 Pedicle soft tissue CDT: A pedicle flap of gingiva can be raised from an edentulous ridge, adjacent teeth or from the existing gingival on the Tooth numbers, current graft procedure tooth and moved laterally or coronally to replace alveolar mucosa as marginal tissue. The procedure can be used to periodontal charting (no cover an exposed root or to eliminate a gingival defect if the root is not too prominent in the arch. more than 12 months old) showing measurements of This procedure includes split thickness grafts and is considered to include three months of post-operative care and any recession, and amount of surgical re-treatment for three years. pre­surgical attached Rationale: gingiva 1. Pedicle soft tissue grafts are usually provided to arrest progressive or clefting of a single tooth. The procedure is also performed when there is no attached gingiva but there is adequate donor tissue adjacent to the defect eliminating a second surgical procedure from a distant donor site. 2. This procedure is performed to increase the zone of attached gingiva, to eliminate the pull of frena or muscle attachments, to extend a vestibular fornix and/or to correct localized progressive gingival recession. It is used where there is not adequate donor tissue adjacent to the defect and thus a separate donor site is necessary.

This procedure is subject to a 60-month time limitation at the same site. Deny. Two (2) millimeters or less of attached gingiva normally indicates the need for this procedure and where there is adequate donor tissue adjacent to the defect. Allow up to two teeth or soft tissue grafts per quadrant, same date of service. Fees for anything more than two sites (teeth) in a quadrant are DENIED.

Subepithelial connective tissue graft procedures, per tooth are considered to include any frenectomy or frenuloplasty performed in the same area on the same date. a. Pay as submitted. b. As a consultant guideline, when multiple non-adjacent grafts are provided within a single quadrant, allow up to two teeth per quadrant. c. DENY benefits for D4273 if membrane is used as opposed to autografts.

Delta Dental Utilization Review Guidelines Page 52 1/1/21 Benefits for GTR/bone grafts/biologic materials in conjunction with soft tissue grafts in the same surgical area are DENIED. Crown lengthening, D4249, performed on the same date of service in conjunction with soft tissue graft procedures in the same quadrant, should not exceed the reimbursement for one quadrant of osseous surgery. D4273 Autogenous CDT: There are two surgical sites. The recipient site utilizes a split thickness incision, retaining the overlapping flap of Tooth numbers, current connective tissue gingiva and/or . The connective tissue is dissected from a separate donor site leaving an epithelialized flap periodontal charting (no graft procedure, for closure. more than 12 months old) (including donor and showing measurements of recipient surgical recession, and amount of sites) first tooth pre­surgical attached implant, or edentulous gingiva tooth position in graft

This procedure is benefited per tooth and subject to a 60-month time limitation. Deny a. Benefits for GTR, in conjunction with soft tissue grafts in the same surgical area, are DENIED. b. Benefits for D4273 are DENIED if membrane is used as opposed to autografts c. Allow up to two teeth or soft tissue grafts per quadrant.

Benefits for a soft tissue graft can be made available if there is an implant present, or if the graft is being done for preparation of implant due to lack of keratinized tissue. A narrative is required. Deny if done for aesthetic purposes.

D4283 Autogenous Used in conjunction with D4273. Tooth numbers, current connective tissue a. Allow up to two teeth or soft tissue grafts per quadrant. Fees for anything more than two sites (teeth) in a quadrant periodontal charting (no graft procedure are DENIED. more than 12 months old) (including donor and b. Benefits for GTR and or bone grafts, in conjunction with soft tissue grafts in the same showing measurements of recipient surgical surgical area, are DENIED. recession, and amount of c. Fees for a frenulectomy D7961, D7962 or frenuloplasty D7963 are not billable to the patient by a participating dentist pre­surgical attached additional contiguous when performed in conjunction with soft tissue grafts. gingiva tooth, implant or Dental Consultant Criteria note: Adjacent teeth in the area of 24 and 25 treat one as a graft and one as additional graft. edentulous tooth position in same graft site

D4275 Non-autogenous CDT: There is only a recipient surgical site utilizing split thickness incision, retaining the overlaying flap of gingiva and/or Tooth numbers, current connective tissue mucosa. A donor surgical site is not present. periodontal charting (no graft (including more than 12 months old) recipient site and showing measurements of donor material) first recession, and amount of tooth, implant, or pre­surgical attached edentulous tooth gingiva position in graft Allow up to two teeth or soft tissue grafts per quadrant.

Delta Dental Utilization Review Guidelines Page 53 1/1/21 D4285 Non-autogenous Used in conjunction with D4275. Tooth numbers, current connective tissue a. Allow up to two teeth soft tissue grafts per quadrant. Fees for anything more than two sites (teeth) in a quadrant are periodontal charting (no graft procedure DENIED. more than 12 months old) (including recipient b. Benefits for GTR and or bone grafts, in conjunction with soft tissue grafts in the same surgical area, are DENIED. showing measurements of surgical site and c. Fees for a frenulectomy D7961, D7962 or frenuloplasty D7963 are not billable to the patient by a participating dentist recession, and amount of when performed in conjunction with soft tissue grafts. pre ­ surgical attached additional contiguous Dental Consultant Criteria/Note: Adjacent teeth in the area of 24 and 25 treat one as a graft and one as additional graft. gingiva tooth, implant or edentulous tooth position in same graft site

D4274 Mesial/distal wedge CDT: This procedure is performed in an edentulous area adjacent to a tooth, allowing removal of a tissue wedge to gain Narrative and pre- procedure, single access for debridement, permit close flap adaptation, and reduce pocket depths. operative periapical x-ray tooth (when not performed in Not a separate benefit when performed in conjunction with surgical procedures in the same anatomical area. Procedure conjunction with is limited to once in a 24-month period. A healing period of at least 14 days is required before any other definitive surgical procedures in treatment at the site is considered. the same anatomical No payment is made for a distal wedge when submitted in conjunction with other surgical procedures on the same date area) of service and in the same surgical site, specifically: osseous surgery (D4260/D4261), gingivectomy (D4210/D4211), gingival flap procedures (D4240/D4245) and crown lengthening (D4249), The fee is not billable to the patient by a participating dentist as it is considered part of the greater surgical procedure/DENIED to the non-participating dentist

Limitation: This procedure is limited to once in 24 months on the same tooth. No payment is made if performed again within that time period by the same participating dentist, must be reviewed by Consultant to determine if the fee is not billable to the patient by a participating dentist or if it will be denied. D4276 Combined connective CDT: Advanced gingival recession often cannot be corrected with a single procedure. Combined tissue grafting Tooth numbers, current tissue and double procedures are needed to achieve the desired outcome. periodontal charting (no pedicle graft, per Delta Dental will make an alternate benefit allowance of a D4273 (subepithelial connective tissue graft) towards this more than 12 months old) tooth procedure. The patient is responsible for the balance up to the dentist's charge. showing measurements of recession, and amount of pre­surgical attached gingiva

D4277 Free soft tissue graft Pay once for first tooth or edentulous tooth position in graft per quadrant. Tooth numbers, current procedure (including Two (2) millimeters or less of attached gingiva normally indicates the need for this procedure. No additional benefits are periodontal charting (no donor site surgery), allowed for harvesting the graft from the donor site. Use of synthetic tissue is not included in the allowance and is more than 12 months old) first tooth or chargeable to the patient as a non-covered benefit. showing measurements of edentulous tooth recession, and amount of position in graft pre­surgical attached gingiva

Delta Dental Utilization Review Guidelines Page 54 1/1/21 D4278 Free soft tissue graft CDT: Used in conjunction with D4277. Tooth numbers, current procedure (including a. Allow up to two teeth per quadrant. periodontal charting (no donor site surgery), b. Benefits for GTR and or bone grafts, in conjunction with soft tissue grafts in the same surgical area, are DENIED. more than 12 months old) each additional c. No payment is made for a frenulectomy D7961, D7962 or frenuloplasty D7963 and the fees are not billable to the showing measurements of contiguous tooth or patient by a participating dentist when performed in conjunction with soft tissue grafts. recession, and amount of edentulous tooth pre­surgical attached position in same graft gingiva site

Benefits for a soft tissue graft can be made available if there is an implant present, or if the graft is being done for preparation of implant due to lack of keratinized tissue. A narrative is required. Deny if done for aesthetic purposes.

When reviewing procedures D4277 and D4278, count each tooth and bounded tooth space as a site. Example: #18 & #20 are being treated; #19 is missing. Benefit #18 as D4277, change tooth #19 to X and benefit as D4278 and #20 as D4278. Up to two contiguous tooth positions may be considered a single site. If the edentulous bounded space is greater than two teeth, consider the bounding teeth being grafted as two separate sites. For participating dentists, the patient cannot be billed for the difference. For non-participating dentists, the patient

considered two separate surgical sites.

capture graft history (using tooth # in an edentulous space is prohibited as extraction may be in history).

Crown lengthening, D4249, performed on the same date of service in conjunction with soft tissue graft procedures in the same quadrant, should not exceed the reimbursement for one quadrant of osseous surgery. NON-SURGICAL PERIODONTAL SERVICE D4320 Provisional splinting ­ CDT: This is an interim stabilization of mobile teeth. A variety of methods and appliances may be employed for this intracoronal purpose. Identify the teeth involved. D4321 Provisional splinting ­ CDT: This is an interim stabilization of mobile teeth. A variety of methods and appliances may be employed for this extracoronal purpose. Identify the teeth involved. DENIED unless covered by group/individual contract. D4341 Periodontal scaling & CDT: This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus FMX, Full mouth perio root planing-four or from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. charting including 4 to 6 more teeth per Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or probing depths per tooth; quadrant permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure indication of furcation may be used as a definitive treatment in some stages of periodontal disease and/or as a part of pre-surgical procedures involvement, mobility, or in others. bleeding upon probing.

Delta Dental Utilization Review Guidelines Page 55 1/1/21 a. Document at least 4mm pocket depths on the diseased teeth involved. No payment is made and the fees are not billable to the patient by a participating dentist in the absence of radiographic documentation of bone loss and documentation of . b. Do not count teeth bounded spaces for D4210, D4341. Count only diseased teeth. c. When there is a contractual time limitation on the frequency of benefits for scaling and root planing, and subsequent requests for scaling and root planing benefits are submitted within that contractual time limitation, benefits are DENIED. In the absence of a contractual time limitation for scaling and root planing, fees are not billable to the patient by a participating dentist for 24 months after the initial therapy if the retreatment is performed by the same dentist/dental office. If treatment is done by a different dentist within 24 months, benefits are DENIED. d. Adult prophylaxis procedures (D1110), full mouth scaling (D4346) or debridement (D4355) are considered a component when submitted on the same date of service as D4341. This time limitation, like all other contractual time limitations, should be defined in the group/individual contract. Fees for the prophylaxis procedure by the same dentist/dental office are not billable to the patient by a participating dentist. e. Benefit no more than two quadrants of scaling and root planing on the same date of service. More than two quadrants on the same date of service are not billable to the patient by the same participating dentist/dental office/DENIED-non- participating dentist. f. For patients under the age of 30, clinical treatment notes, the most current (less than two years old) complete series of radiographic images, complete periodontal charting (no more 12 months old) and a copy of the appointment schedule showing the length of the appointment time are required.

No payment is made for periodontal maintenance (D4910), scaling in presence of generalized moderate or severe gingival inflammation (D4346) or prophylaxis (D1110) when performed on the same day as scaling and root planning (D4341). The fee is not billable to the patient by a participating dentist.

D4342 Periodontal scaling & Scaling and root planing in the same quadrant is benefited once every 24 months unless specified by group contract. root planing-one to three teeth per quadrant Reporting separately for periodontal root planing is not billable to the patient by a participating dentist on the same date as procedures D4240-D4241, D4249, D4260-4261, D4270-D4285. Do not count tooth bounded spaces for D4341, D4342. In order to qualify for benefits probing depths must be 4mm or greater on 4 or more teeth. If only 1-3 teeth qualify, use partial quadrant code (D4342). If no teeth in the quadrant qualify, the Dental Consultant will DENY. D4346 Scaling in presence of CDT: The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized generalized moderate moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, or severe gingival inflamed gingiva, generalized suprabony pockets, and moderate to severe . Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures. mouth, after oral evaluation

a. D4346 is included in frequency for D1110 or D1120. b. Benefits D4346 include prophylaxis, fees for D1110, D1120 or D4355 are not billable to the patient by a participating dentist when submitted with D4346 by the same dentist/dental office. c. No payment is made for D4346 and the fees are not billable to the patient by a participating dentist when submitted with D4910 by the same dentist/dental office.

D4355 Full mouth CDT: Full mouth debridement involves the preliminary removal of plaque and calculus that interfere with the ability of debridement to the dentist to perform a comprehensive oral evaluation. Not to be completed on the same day as D0150, D0160, or enable a D0180. comprehensive evaluation and diagnosis on a Delta Dentalsubsequent Utilization visit Review Guidelines Page 56 1/1/21 Full mouth debridement to enable a comprehensive a. If D1110-adult prophy, D1120-child prophy, D4341/D4342-scaling and root planing, D4346-scaling in presence of evaluation and generalized moderate or severe gingival inflammation, D4355-full mouth debridement, or D4910-periodontal diagnosis on a maintenance has been paid within the past 24 months to the same participating dentist/dental office, benefit as D1110 subsequent visit with no patient liability (except for co-insurance if applicable). b. D4355 will count against prophylaxis frequency limitations. c. No payment is made for D4355 and the fee is not billable to the patient by a participating dentist when performed by the same dentist/dental office on the same day as D0150, D0160, or D0180. If the patient has not been to the dentist in several years and in order to do a proper evaluation and diagnosis, and the dentist is unable to accomplish effective prophylaxis under normal conditions, then D4355 will be benefited. Rationale: Periodic evaluation (D0120) is not included because it is not a comprehensive evaluation. Evaluation codes are not allowed on same date of service as a D4355, according to the ADA descriptor.

D4381 Localized delivery of CDT: FDA approved subgingival delivery devices containing antimicrobial medication(s) are inserted into periodontal antimicrobial agents pockets to suppress the pathogenic microbiota. These devices slowly release the pharmacological agents so they can via a controlled remain at the intended site of action in a therapeutic concentration for a sufficient length of time. release vehicle into diseased crevicular DENIED unless covered by group/individual contract. tissue, per tooth

OTHER PERIODONTAL SERVICES D4910 Periodontal CDT: This procedure is instituted following periodontal therapy and continues at varying intervals, determined by the maintenance clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment procedures must be considered. a. Benefits are allowed if there is evidence of periodontal therapy in history (procedures D4240, D4241, D4260,D4261, D4341, D4342, D4910) or documentation from the treating dentist that active periodontal treatment has been performed. If there is no evidence of periodontal therapy in history, deny D4910. b. If an oral examination (D0120) is submitted and benefited on same day as D4910, the evaluation counts toward evaluation frequency limits. c. Benefits for D4910 include prophylaxis and scaling and root planing procedures. Fees for these procedures by the same dentist/dental office are not billable to the patient by a participating dentist when billed on the same date of service as the periodontal maintenance. d. No payment is made for D4910 when billed within 30 days of periodontal therapy by the same dentist/dental office and the fees are not billable to the patient by a participating dentist. e. If a D0180 is submitted with a D4910 by the same dentist/dental office it is benefited as a D0120 and the difference in the approved amount between the D0120 and the D0180 is not billable to the patient by a participating dentist on the same date of service, unless the D0180 is the initial evaluation by the dentist rendering the D4910.

Some contracts provide for 2 periodontal maintenance procedures in a calendar/policy year period; some contracts allow 1 every 6 months. If the patient receives a 3rd and/or 4th periodontal maintenance procedure, allow an alternate

An office may pre-treat both periodontal maintenance (D4910) with scaling and root planing (code D4341) and/or osseous surgery (code D4260) on the same pre-treatment form.

Delta Dental Utilization Review Guidelines Page 57 1/1/21 **A minimum healing period of 30 days is required following D4341 or periodontal surgery. D4920 Unscheduled dressing DENIED unless covered by group/individual contract. change (by someone other than treating dentist or their staff)

D4921 CDT: Irrigation of gingival pockets with medicinal agent. Not to be used to report use of mouth rinses or non-invasive per quadrant chemical debridement. a. When gingival irrigation is submitted as a standalone procedure, medicaments and solutions used for gingival irrigation are not covered benefits and the benefits are DENIED. b. Fees for gingival irrigation are not billable to the patient when performed with any periodontal service.

D4999 Unspecified CDT: Use for periodontal procedure that is not adequately described by a code. Describe procedure. Narrative periodontal May require IC review by Dental Consultant. procedure, by report

LANAP (laser assisted new attachment procedure) should be submitted as code D4999. LANAP is not covered and is the patient's responsibility. Procedure D4341 performed in conjunction with LANAP may be submitted separately.

General policy - Perioscopy is a technique not a procedure. No payment is made for Perioscope and the fees are not billable to the patient by a participating dentist. Benefits for Perioscopy as a stand alone procedure are DENIED as investigational. Rationale: Claims are based on the procedure, not the technology used.

PROSTHODONTICS (Removable) D5000-D5899 **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.** Benefits are payable on the date the denture is delivered. Pre-treatment estimates are recommended for all prosthodontic procedures. General Policy: Removable cast partials are not a benefit for patients under age 16.

conventional methods are adequate. COMPLETE (Including Routine Post-Delivery Care) D5110 Complete denture- Dentures are benefited once in a 60-month period and include any reline/rebase, adjustment or repair required within 6 maxillary months of delivery except in the cases of immediate dentures. Benefits may be DENIED if repair or replacement within

D5120 Complete denture- Tissue conditioning is not a benefit if performed on the same day the denture is delivered. mandibular Specialized techniques, personalization or characterization, dolder bars, hader bars and swinglocks are not covered and if performed should be done with the prior agreement of the patient to assume the additional cost. Any enhancements should be submitted on the claim form using code D5899. D5130 Immediate denture- CDT: Includes limited follow-up care only; does not include required future rebasing/relining procedure(s). maxillary D5140 Immediate denture- CDT: Includes limited follow-up care only; does not include required future rebasing/relining procedure(s). mandibular PARTIAL DENTURES (Including Routine Post-Delivery Care)

Delta Dental Utilization Review Guidelines Page 58 1/1/21 D5211 Maxillary partial Partial dentures are benefited once per arch per 60 months and include any reline/rebase, adjustment or repair required denture-resin base within 6 months of delivery. Benefit allowance includes frame, clasps, rests and teeth. (including retentive/clasping materials, rests, and teeth) Tissue conditioning is not a benefit if performed on the same day the denture is delivered. Specialized techniques, personalization or characterization, dolder bars, hader bars and swinglocks are not covered and if performed should be done with the prior agreement of the patient to assume the additional cost. Any enhancements should be submitted on the claim form using code D5899. D5212 Mandibular partial See D5211 for Guidelines. denture-resin base (including retentive/clasping materials, rests, and teeth) D5213 Maxillary partial See D5211 for Guidelines. denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) D5214 Mandibular partial See D5211 for Guidelines. denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) D5221 Immediate maxillary CDT: Includes limited follow-up care only; does not include future rebasing /relining procedure(s).

base (including retentive/clasping materials, rests and teeth)

D5222 Immediate mandibular CDT: Includes limited follow-up care only; does not include future rebasing /relining procedure(s).

base (including retentive/clasping materials, rests and teeth)

Delta Dental Utilization Review Guidelines Page 59 1/1/21 D5223 Immediate maxillary CDT: Includes limited follow-up care only; does not include future rebasing /relining procedure(s).

metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5224 Immediate mandibular CDT: Includes limited follow-up care only; does not include future rebasing /relining procedure(s).

metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5225 Maxillary partial To be used for flexible partial dentures. Same limitations as resin or cast partials. denture - flexible base If a narrative states metal enforcements or another specialized technique is included with the flexible partial, the dentist (including may bill the patient up to charge. retentive/clasping materials, rests and teeth)

D5226 Mandibular partial To be used for flexible dentures. Same limitations as resin or cast partials. denture - flexible base If a narrative states metal enforcements or another specialized technique is included with the flexible partial, the dentist (including may bill the patient up to charge. retentive/clasping materials, rests and teeth) *Delta Dental will not allow an additional benefit for a posterior bridge in conjunction with an allowance for a partial denture in the same arch. If performed, the service must be done with the agreement of the patient to assume the cost.

D5282 Removable unilateral Partial dentures are benefited once per arch per 60 months and include any reline/rebase, adjustment or repair required within 6 months of delivery. Benefit allowance includes frame, clasps, rests and teeth. piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

D5283 Removable unilateral

piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

Delta Dental Utilization Review Guidelines Page 60 1/1/21 D5284 Removable unilateral

piece flexible base (including retentive/clasping materials, rests, and

D5286 Removable unilateral

piece resin (including retentive/clasping materials, rests, and

Scenario 1: If a provider submits a claim for two Nesbit partial dentures (procedure code D5282 or D5283) in the same arch on the same day, combine the office charges and process with the appropriate cast partial denture procedure code

Scenario 2: If two Nesbit partials are rendered on different dates of services within 60 months of each other: ~First Nesbit is paid as procedure code D5282 or D5283. ~The allowance for the two Nesbit partials can not exceed the allowance for a cast partial denture. To calculate the allowance for the 2nd Nesbit: take allowance for cast partial denture, and subtract what was allowed for the Nesbit = the amount allowed for the second Nesbit. Process the second Nesbit as an alternate benefit by using the calculated amount from the above equation as the allowed amount. The approved would be the office charge. The patient is responsible for the difference up to the dentist's charge. Also, the 60 month time limitation starts from the insert date of the second Nesbit. ADJUSTMENTS TO DENTURES D5410 Adjust complete Full or partial dentures include any adjustments, repairs, rebases and relines within 6 months of delivery except in the denture - maxillary case of immediate dentures. Immediate dentures are exempt from the time limitation. Two denture/partial adjustments per calendar year are covered after the first 6 months following initial placement. Any additional adjustments are the patient's responsibility. D5411 Adjust complete denture - mandibular

D5421 Adjust partial denture - maxillary D5422 Adjust partial denture - mandibular

REPAIRS TO D5511 Repair broken Full or partial dentures include any adjustments, repairs, rebases and relines within 6 months of delivery except in the complete denture case of immediate dentures. Immediate dentures are exempt from the time limitation. One denture/partial repair per base, mandibular calendar year is covered after the first 6 months following initial placement. Any additional repairs are the patient's responsibility. The total benefit allowed for the repair of the denture should not exceed half of the prevailing amount of a new denture.

Delta Dental Utilization Review Guidelines Page 61 1/1/21 D5512 Repair broken complete denture base, maxillary D5520 Replace missing or No payment is made for repairs of complete or partial dentures if performed within six months of initial placement by the broken teeth - same dentist/dental office and the fees are not billable to the patient by a participating dentist. complete denture (each tooth) REPAIRS TO PARTIAL DENTURES D5611 Repair resin partial Full or partial dentures include any adjustments, repairs, rebases and relines within 6 months of delivery except in the denture base, case of immediate dentures. Immediate dentures are exempt from the time limitation. One denture/partial repair per mandibular calendar year is covered after the first 6 months following initial placement. Any additional repairs are the patient's responsibility. The total benefit allowed for the repair of the denture should not exceed half of the prevailing amount of a new denture. D5612 Repair resin partial denture base, maxillary D5621 Repair cast partial framework, mandibular D5622 Repair cast partial framework, maxillary D5630 Repair or replace Since special prosthetic devices are not a covered benefit, repairs to these devices are excluded. The patient is broken responsible for the additional cost. retentive/clasping materials - per tooth D5640 Replace broken teeth- per tooth D5650 Add tooth to existing partial denture

D5660 Add clasp to existing partial denture - per tooth D5670 Replace all teeth and Benefits for D5670 and D5671 are allowed only if the existing partial is over 60 months old. acrylic on cast metal framework (maxillary)

D5671 Replace all teeth and If a new partial is submitted within 60 months of procedure codes D5670 and D5671, it will be denied. acrylic on cast metal framework (mandibular) DENTURE REBASE PROCEDURES Rebase - process of refitting a denture by replacing the base material D5710 Rebase complete Rebase includes adjustments and reline required within 6 months of delivery of the rebased denture. Benefits are maxillary denture allowed once in a 60 month period. D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture

Delta Dental Utilization Review Guidelines Page 62 1/1/21 D5721 Rebase mandibular partial denture DENTURE RELINE PROCEDURES Reline is the process of resurfacing the tissue side of a denture with new base material D5730 Reline complete Reline includes all adjustments required within 6 months of delivery of the relined denture. Benefits for reline are allowed maxillary denture once in a 60 month period. (chairside direct) D5731 Reline complete mandibular denture (chairside direct) D5740 Reline maxillary partial denture (chairside direct) D5741 Reline mandibular partial denture (chairside direct) D5750 Reline complete maxillary denture (laboratory indirect) D5751 Reline complete mandibular denture (laboratory indirect) D5760 Reline maxillary partial denture (laboratory indirect) D5761 Reline mandibular partial denture (laboratory indirect) INTERIM PROSTHESIS A provisional prosthesis designed to use over a limited period of time, after which it is to be replaced by a more definitive restoration. D5810 Interim complete DENIED unless covered by group/individual contract. denture-maxillary D5811 Interim complete DENIED unless covered by group/individual contract. denture-mandibular D5820 Interim partial denture (including anterior permanent teeth. retentive/clasping Rationale: Benefits are provided only for definitive treatment. Temporary appliances are contract exclusions. materials, rests, and teeth), maxillary

D5821 Interim partial denture (including teeth. retentive/clasping Rationale: Benefits are provided only for definitive treatment. Temporary appliances are contract exclusions. materials, rests, and teeth), mandibular

OTHER REMOVABLE PROSTHETIC SERVICES

Delta Dental Utilization Review Guidelines Page 63 1/1/21 D5850 Tissue conditioning - CDT: Treatment reline using materials designed to heal unhealthy ridges prior to more definitive final restoration. maxillary D5851 Tissue conditioning - Tissue conditioning is a benefit twice per calendar year. mandibular The fee for tissue conditioning done on the same day the denture is delivered or a reline/rebase is provided by the same dentist/dental office and is not billable to the patient by a participating provider. D5862 Precision attachment, CDT: Each set of male and female components should be reported as one precision attachment. Describe the type of by report attachment used.

D5863 Complete and partial overdentures are considered specialized techniques and the benefit for an overdenture procedure complete maxillary is DENIED. An allowance will be made for a conventional denture, and any excess fee is chargeable to the patient. Rationale: 1. Extra fees for specialized procedures are exclusions; therefore, an alternate benefit is made. 2. An overdenture is considered a specialized elective procedure over and above that which is normally adequate. Subscriber contracts exclude specialized procedures. Payment will be made for overdentures at the maximum plan allowance for a conventional denture, with additional costs (e.g., for endodontic therapy, copings and attachments) chargeable to the patient.

D5864 See above. maxillary D5865 See above. complete mandibular

D5866 See above. mandibular D5867 Replacement of There is a 60-month time limitation for replacement of precision attachments. replaceable part of semi-precision or precision attachment (male or female component)

D5875 Modification of CDT: Attachment assemblies are reported using separate codes. removable prosthesis following implant surgery

If implant services are covered, benefits for D5875 are DENIED as a specialized procedure. D5876 Add metal Benefits are DENIED as a specialized procedure. substructure to acrylic Dental Consultant Criteria/Note: This procedure is for a new appliance and not for a repair of an existing appliance. full denture (per arch)

D5899 Unspecified CDT: Use for a prosthodontic procedure that is not adequately described by a code. Describe procedure. Narrative removable prosthodontic procedure, by report

May require IC review by Dental Consultant. MAXILLOFACIAL PROSTHETICS D5900-D5999 Procedure codes D5911 through D5993: DENIED unless covered by group/individual contract.

Delta Dental Utilization Review Guidelines Page 64 1/1/21 For full definitions of procedure codes refer to Current Dental Terminology (CDT) Book D5992 Adjust maxillofacial prosthetic appliance, by report D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report

D5914 Auricular prosthesis D5927 Auricular prosthesis replacement D5987 Commissure splint D5924 Cranial prosthesis D5925 Facial augmentation implant prosthesis D5912 Facial moulage (complete) D5911 Facial moulage (sectional) D5919 Facial prosthesis D5929 Facial prosthesis replacement D5951 Feeding aid

D5934 Mandibular resection prosthesis with guide flange D5935 Mandibular resection prosthesis without guide flange

D5913 Nasal prosthesis D5926 Nasal prosthesis, replacement D5922 Nasal septal prosthesis

D5932 Obturator prosthesis, definitive D5936 Obturator prosthesis, interim D5933 Obturator prosthesis, modification

D5931 Obturator prosthesis, surgical

Delta Dental Utilization Review Guidelines Page 65 1/1/21 D5916 Ocular prosthesis D5923 Ocular prosthesis, interim D5915 Orbital prosthesis D5928 Orbital prosthesis replacement D5954 Palatal augmentation prosthesis

D5955 Palatal lift prosthesis, definitive D5958 Palatal lift prosthesis, interim D5959 Palatal lift prosthesis, modification

D5985 Radiation cone locator D5984 Radiation shield D5953 Speech aid prosthesis, adult D5960 Speech aid prosthesis, modification

D5952 Speech aid prosthesis, pediatric D5988 Surgical splint D5982 Surgical stent D5937 appliance (not for TMD treatment) CARRIERS D5986 Fluoride gel carrier D5995 Periodontal CDT: A custom fabricated, laboratory processed carrier for the maxillary arch that covers the teeth and alveolar mucosa. medicament carrier Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket. laboratory processed

DENIED unless covered by group/individual contract. D5996 Periodontal CDT: A custom fabricated, laboratory processed carrier for the mandibular arch that covers the teeth and alveolar medicament carrier mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket. laboratory processed

DENIED unless covered by group/individual contract. D5983 Radiation carrier D5991 Vesiculobullous CDT: A custom fabricated carrier that covers the teeth and alveolar mucosa, or alveolar mucosa alone, and is used to disease medicament deliver prescription medicaments for treatment of immunologically mediated vesiculobullous diseases. carrier

Delta Dental Utilization Review Guidelines Page 66 1/1/21 DENIED unless covered by group/individual contract. D5999 Unspecified CDT: Used for a procedure that is not adequately described by a code. Describe procedure. Narrative maxillofacial May require IC review by Dental Consultant. prosthesis, by report IMPLANT SERVICES D6000-D6199 **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.** The time limitation for implants is established by contract. Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

Implants and implant services are not a benefit for patient's under 19 years of age. Individual consideration may be given for implant placement based upon a narrative indicating the completion of growth has been considered. Rationale: Published reports and consensus conferences have recommended that whenever possible, implant placement must be delayed until growth is complete. *Note:

Fees for study models used in preparation of implant placement are denied.

conventional methods are adequate. Codes covered if the subscriber's contract has a single tooth implant benefit: D6010, D6013, D6056, D6057 and D6095. Codes covered if the subscriber's contract has Implant Rider: D6010, D6013, 6040, D6050, D6055, D6056, D6057, D6091, D6095, D6100, D6199 and D6080. Codes covered at the Prosthodontic benefit level for both the implant rider and single tooth implant benefit: D6090, D6092 and D6093.

PRE-SURGICAL SERVICES D6190 Radiographic/ CDT: An appliance, designed to relate osteotomy or fixture position to existing anatomic structures, to be utilized during surgical implant index, radiographic exposure for treatment planning and/or during osteotomy creation for fixture installation. by report DENIED unless covered by group/individual contract. SURGICAL SERVICES Report surgical implant procedures using codes in this section. D6010 Surgical placement of Not a covered benefit unless the subscriber's contract has an Implant Rider or single tooth implant benefit. implant body: endosteal implant Delta Dental will only make payment for the replacement of missing natural teeth. Implants done solely to restore a space beyond the normal complement of natural teeth is optional. The patient is responsible for the entire cost of the implant. D6011 Surgical access to an CDT: This procedure, also known as second stage implant surgery, involves removal of tissue that covers the implant implant body (second body so that a fixture of any type can be placed, or an existing fixture be replaced with another. Examples of fixtures stage implant include but are not limited to healing caps, abutments shaped to help contour the gingival margins or the final surgery) restorative prosthesis.

a. Considered to be part of D6010/6012/6013 and fees for D6011 are not billable to the patient by a participating dentist. b. Benefits for D6011 are DENIED if done by a different dentist/dental office.

D6012 Surgical placement of CDT: Includes removal during later therapy to accommodate the definitive restoration, which may include placement of interim implant body other implants. for transitional prosthesis: endosteal implant Delta Dental Utilization Review Guidelines Page 67 1/1/21 Surgical placement of interim implant body for transitional DENIED unless covered by group/individual contract. prosthesis: endosteal implant

D6013 Surgical placement of Time limitation is established by subscriber's contract following the time limitation for implants. mini implant D6040 Surgical placement: CDT: An eposteal (subperiosteal) framework of a biocompatible material designed and fabricated to fit on the surface of eposteal implant the bone of the mandible or maxilla with permucosal extensions that provide support and attachment of a prosthesis. This may be a complete arch or unilateral appliance. Eposteal implants rest upon the bone and under the periosteum.

Not a covered benefit unless the subscriber's contract has an Implant Rider. D6050 Surgical placement: CDT: A transosteal (transosseous) biocompatible device with threaded posts penetrating both the superior and inferior transosteal implant cortical bone plates of the mandibular symphysis and exiting through the permucosa providing support and attachment for a . Transosteal implants are placed completely through the bone and into the oral cavity from extraoral or intraoral. Not a covered benefit unless the subscriber's contract has an Implant Rider. D6100 Implant removal, by CDT: This procedure involves the surgical removal of an implant. Describe procedure. Narrative report Not a covered benefit unless the subscriber's contract has an Implant Rider. When implants are covered by the group/individual contract, the fee for D6100 when performed within 3 months of D6010/ D6013 on the same tooth by the same dentist/dental office is not billable to the patient by a participating dentist. After 3 months, benefit once per tooth per frequency limitation for implants/prosthetics.

D6101 Debridement of a a. No payment is made for this procedure and the fee is not billable to the patient by a participating dentist when periimplant defect or performed in the same surgical site by the same dentist/dental/office on the same day as D6102. defects surrounding a b. DENY if implants are not a covered benefit. single implant, and c. No payment is made when D6101 is billed in conjunction with D4260 or D4261 and the fee is not billable to the patient surface cleaning of by a participating dentist. the exposed implant surfaces, including flap entry and closure

D6102 Debridement and a. DENY if implants are not a covered benefit. osseous contouring of b. Any items in the nomenclature (D4240, D4241, D4260 and D4261) listed separately should be billable to the patient a periimplant defect by a participating dentist in conjunction with this procedure. or defects c. Fees for D6102 are not billable to the patient by a participating dentist when billed in conjunction with D4260 or surrounding a single D4261. implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure

Delta Dental Utilization Review Guidelines Page 68 1/1/21 D6103 Bone graft for repair CDT: Placement of a or biologic materials to aid in osseous regeneration, are reported separately. of periimplant defect Not a covered benefit. Benefits for these procedures when billed in conjunction with implants, implant removal, ridge augmentation or entry and closure. preservation, in extraction sites, periradicular surgery, etc. are DENIED.

these procedures when billed in conjunction with implants, implant removal, ridge augmentation or preservation, in extraction sites, periradicular surgery, etc. are DENIED. Sufficient longitudinal study data on outcomes is not available.

D6104 Bone graft at time of CDT: Placement of a barrier membrane, or biologic materials at aid in osseous regeneration are reported separately. implant placement Not a covered benefit.

these procedures when billed in conjunction with implants, implant removal, ridge preservation, in extraction sites, periradicular surgery, etc. are DENIED.

IMPLANT SUPPORTED PROSTHETICS Supporting Structures D6055 Connecting bar- CDT: Utilized to stabilize and anchor a prosthesis. implant supported or abutment supported

Not a covered benefit unless the subscriber's contract has an Implant Rider. Benefits for a placement of an implant to a natural tooth bridge are denied for long term prognosis. The risk associated with the placement of a bridge with one abutment on a natural tooth and the second on an implant is substantial.

D6056 Prefabricated CDT: Modification of a prefabricated abutment may be necessary. abutment-includes modification and placement Not a covered benefit unless the subscriber's contract has an Implant Rider or single tooth implant benefit.

"Easy Abutments" submitted as D6199 or D6999 should be recoded to D6056. D6057 Custom fabricated CDT: Created by a laboratory process, specific for an individual application. abutment-includes placement Not a covered benefit unless the subscriber's contract has an Implant Rider or single tooth implant benefit.

D6051 Interim abutment CDT: Includes placement and removal. A healing cap is not an interim abutment. Temporary and interim fixed prostheses are not separate benefits and should be included in the fee for the permanent prostheses. Separate fees by the same dentist/dental office are not billable to the patient by a participating dentist.

D6191 Semi-precision CDT: This procedure is the initial placement, or replacement, of a semi-precision abutment on the implant body.

Benefits are DENIED as a specialized technique/procedure unless covered by the group/individual contract. D6192 Semi-precision CDT: This procedure involves the luting of the initial, or replacement, semi-precision attachment to the removable prosthesis. placement

Delta Dental Utilization Review Guidelines Page 69 1/1/21 Benefits are DENIED as a specialized technique/procedure unless covered by the group/individual contract. Implant/Abutment Supported Removable Dentures Implant supported dentures or partials are not covered; however, an alternate benefit allowance is made of a

D6110 Implant /abutment An implant supported denture is not covered; however an alternate benefit allowance will be made of a conventional Panoramic film and/or supported removable appropriate periapical x- denture for ray

maxillary D6111 Implant /abutment An implant supported denture is not covered; however an alternate benefit allowance will be made of a conventional Panoramic film and/or supported removable appropriate periapical x- denture for ray

mandibular D6112 Implant /abutment An implant supported partial denture is not covered; however an alternate benefit allowance will be made of a Panoramic film and/or supported removable appropriate periapical x- denture for partially charge. ray

maxillary

D6113 implant /abutment An implant supported partial denture is not covered; however an alternate benefit allowance will be made of a Panoramic film and/or supported removable appropriate periapical x- denture for partially charge. ray

mandibular

The risk associated with the placement of a bridge with one abutment on a natural tooth and the second on an implant is substantial. Benefits are denied for long term prognosis. Implant/Abutment Supported Fixed Dentures (Hybrid Prosthesis) D6114 Implant /abutment An implant supported denture is not covered; however an alternate benefit allowance will be made of a conventional Panoramic film and/or supported fixed appropriate periapical x- denture for ray

maxillary D6115 Implant /abutment An implant supported denture is not covered; however an alternate benefit allowance will be made of a conventional Panoramic film and/or supported fixed appropriate periapical x- denture for ray

mandibular D6116 Implant /abutment An implant supported partial denture is not covered; however an alternate benefit allowance will be made of a Panoramic film and/or supported fixed appropriate periapical x- denture for partially charge. ray

maxillary D6117 Implant /abutment An implant supported partial denture is not covered; however an alternate benefit allowance will be made of a Panoramic film and/or supported fixed appropriate periapical x- denture for partially charge. ray

mandibular

Delta Dental Utilization Review Guidelines Page 70 1/1/21 The risk associated with the placement of a bridge with one abutment on a natural tooth and the second on an implant is substantial. Benefits are denied for long term prognosis. D6118 Implant/abutment CDT: Used when a period of healing is necessary prior to fabrication and placement of a permanent prosthetic. supported interim fixed denture for

mandibular

benefit and are DENIED. Rationale: Benefits are provided only for definitive treatment. Temporary appliances are contract exclusions.

D6119 Implant/abutment CDT: Used when a period of healing is necessary prior to fabrication and placement of a permanent prosthetic. supported interim fixed denture for

maxillary

Rationale: Benefits are provided only for definitive treatment. Temporary appliances are contract exclusions.

Single Crowns, Abutment Supported D6058 Abutment supported CDT: A single crown restoration that is retained, supported and stabilized by an abutment on an implant. porcelain/ceramic crown

D6059 Abutment supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment on an implant. porcelain fused to metal crown (high noble metal)

D6060 Abutment supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment on an implant, porcelain fused to metal crown (predominately base metal)

D6061 Abutment supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an abutment on an implant. porcelain fused to metal crown (noble metal) D6097 Abutment supported CDT: A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant. crown - porcelain fused to titanium and titanium alloys

D6062 Abutment supported CDT: A single cast metal crown restoration that is retained, supported and stabilized by an abutment on an implant. cast metal crown (high noble metal)

Delta Dental Utilization Review Guidelines Page 71 1/1/21 D6063 Abutment supported CDT: A single cast metal crown restoration that is retained, supported and stabilized by an abutment on an implant. cast metal crown (predominately base metal)

D6064 Abutment supported CDT: A single cast metal crown restoration that is retained, supported and stabilized by an abutment on an implant. cast metal crown (noble metal)

D6094 Abutment supported CDT: A single crown restoration that is retained, supported and stabilized by an abutment on an implant. May be cast or crown - titanium and milled. titanium alloys

Single Crowns, Implant Supported D6065 Implant supported CDT: A single crown restoration that is retained, supported and stabilized by an implant. porcelain/ceramic crown D6066 Implant supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant. crown - porcelain fused to high noble alloys D6067 Implant supported CDT: A single metal crown restoration that is retained, supported and stabilized by an implant. metal crown - high noble alloys Fixed Partial Denture, Abutment Supported The risk associated with the placement of a bridge with one abutment on a natural tooth and the second on an implant is substantial. Benefits are denied for long term prognosis. D6068 Abutment supported CDT: A ceramic retainer for a fixed partial denture that gains retention, support and stability from an abutment on an Pre-operative periapical x- retainer for implant. ray for pre tx and x-ray porcelain/ceramic showing implant for claim FPD

D6069 Abutment supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability from an abutment on Pre-operative periapical x- retainer for porcelain an implant. ray for pre tx and x-ray fused to metal FPD showing implant for claim (high noble metal)

D6070 Abutment supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability from an abutment on Pre-operative periapical x- retainer for porcelain an implant. ray for pre tx and x-ray fused to metal FPD showing implant for claim (predominately base metal)

D6071 Abutment supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability from an abutment on Pre-operative periapical x- retainer for porcelain an implant. ray for pre tx and x-ray fused to metal FPD showing implant for claim (noble metal)

Delta Dental Utilization Review Guidelines Page 72 1/1/21 D6195 Abutment supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on Pre-operative periapical x- retainer - porcelain an implant. ray for pre tx and x-ray fused to titanium and showing implant for claim titanium alloys

D6072 Abutment supported CDT: A cast metal retainer for a fixed partial denture that gains retention, support and stability from an abutment on an Pre-operative periapical x- retainer for cast metal implant. ray for pre tx and x-ray FPD (high noble) showing implant for claim

D6073 Abutment supported CDT: A cast metal retainer for a fixed partial denture that gains retention, support and stability from an abutment on an Pre-operative periapical x- retainer for cast metal implant. ray for pre tx and x-ray FPD (predominately showing implant for claim base metal)

D6074 Abutment supported CDT: A cast metal retainer for a fixed partial denture that gains retention, support and stability from an abutment on an Pre-operative periapical x- retainer for cast metal implant. ray for pre tx and x-ray FPD (noble metal) showing implant for claim

D6194 Abutment supported CDT: A retainer for a fixed partial denture that gains retention, support and stability from an abutment on an implant. Pre-operative periapical x- retainer for FPD - ray for pre tx and x-ray titanium and titanium showing implant for claim alloys Fixed Partial Denture, Implant Supported The risk associated with the placement of a bridge with one abutment on a natural tooth and the second on an implant is substantial. Benefits are denied for long term prognosis. D6075 Implant supported CDT: A ceramic retainer for a fixed partial denture that gains retention, support and stability from an implant. Pre-operative periapical x- retainer for ceramic ray for pre tx and x-ray FPD showing implant for claim

D6076 Implant supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability from an implant. Pre-operative periapical x- retainer for FPD - ray for pre tx and x-ray porcelain fused to showing implant for claim (high noble alloys) D6098 Implant supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- retainer - porcelain ray for pre tx and x-ray fused to showing implant for claim predominantly base alloys D6099 Implant supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- retainer for FPD - ray for pre tx and x-ray porcelain fused to showing implant for claim noble alloys D6120 Implant supported CDT: A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- ray for pre tx and x-ray fused to titanium and showing implant for claim titanium alloys D6077 Implant supported CDT: A metal retainer for a fixed partial denture that gains retention, support and stability from an implant. Pre-operative periapical x- retainer for metal FPD ray for pre tx and x-ray (high noble) showing implant for claim

Delta Dental Utilization Review Guidelines Page 73 1/1/21 D6121 Implant supported CDT: A metal retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- retainer for metal FPD ray for pre tx and x-ray showing implant for claim alloys

D6122 Implant supported CDT: A metal retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- retainer for metal FPD ray for pre tx and x-ray showing implant for claim

D6123 Implant supported CDT: A metal retainer for a fixed partial denture that gains retention, support, and stability from an implant. Pre-operative periapical x- retainer for metal FPD ray for pre tx and x-ray showing implant for claim titanium alloys OTHER IMPLANT SERVICES D6080 Implant maintenance CDT: This procedure includes active debriding of the implant(s) and examination of all aspects of the implant system(s), Narrative procedures when including the occlusion and stability of the superstructure. The patient is also instructed in thorough daily cleansing of prostheses are the implant(s). This is not a per implant code, and is indicated for implant supported fixed prostheses. removed and a. DENY unless subscriber contract covers implants. reinserted, including b. When submitted on the same date of service, the prophylaxis (D1110) is a benefit. cleansing of c. Allow once every three years. prostheses and abutments

Not a covered benefit unless the subscriber's contract has an Implant Rider. D6081 Scaling and CDT: This procedure is not performed in conjunction with D1110, D4910 or D4346. debridement in the a. Benefits for D6081 are DENIED unless implants are covered by the group/individual contract. presence of b. Fees for D6081 are not billable to the patient by a participating dentist when performed in the same quadrant by the inflammation or same dentist/dental office as D4341/D4342 or D4240/D4241, D4260/D4261 or D6101/D6102. mucositis of a single c. When covered, allow once per tooth per 24 months. implant, including d. No payment is made for retreatment by the same dentist/dental office within 24 months of initial therapy and the fees cleaning of the are not billable to the patient by a participating dentist. If different dentist/dental office then DENY. implant surfaces, e. No payment is made when performed within 12 months of restoration (D6058-D6077, D6085, D6094, D6118, D6119, without flap entry and D6194) placement by same dentist/dental office and the fees are not billable to the patient by a participating dentist. closure f. No payment is made for D6081 and the fees are not billable to the patient by a participating dentist when performed in conjunction with D1110, D4346 or D4910.

D6082 Implant supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant. crown - porcelain fused to predominantly base alloys D6083 Implant supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant. crown - porcelain fused to noble alloys

Delta Dental Utilization Review Guidelines Page 74 1/1/21 D6084 Implant supported CDT: A single metal-ceramic crown restoration that is retained, supported and stabilized by an implant. crown - porcelain fused to titanium and titanium alloys

D6085 Provisional implant CDT: Used when a period of healing is necessary prior to fabrication and placement of permanent prosthetic. crown a. Benefits for provisional implant crowns are DENIED unless covered by group/individual contract. b. Temporary or provisional fixed prostheses by the same dentist/dental office are not separate benefits and should be included in the fee for the permanent prosthesis. Fees for provisional crown are not billable to the patient by a participating dentist. Dental Consultant Criteria/Note: When a temporary (interim) or provisional crown is billed as a therapeutic measure for preservation of gingival architecture, benefits are DENIED subject to individual consideration.

D6086 Implant supported CDT: A single metal crown restoration that is retained, supported and stabilized by an implant. crown - predominantly base alloys D6087 Implant supported CDT: A single metal crown restoration that is retained, supported and stabilized by an implant. crown - noble alloys D6088 Implant supported CDT: A single metal crown restoration that is retained, supported and stabilized by an implant. crown - titanium and titanium alloys D6090 Repair implant CDT: This procedure involves the repair or replacement of any part of the implant supported prosthesis. Narrative supported prosthesis, by report Covered at the Prosthodontic level Repairs are covered once every 60 months. D6091 Replacement of Not a covered benefit unless the subscriber's contract has an Implant Rider. Narrative replaceable part of If covered, benefit once per 24 months. semi-precision or Benefits are DENIED less than 24 months. precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment

D6092 Re-cement or re-bond a. No payment is made for recementation or rebonding of crowns and the fees are not billable to the patient if done implant/abutment within six months of the initial seating date by the same dentist/ dental office. supported crown b. Benefits may be paid for one recementation or rebonding after six months have elapsed since the initial placement. Subsequent requests for recementation or rebonding by the same dentist/dental office are DENIED. Benefits may be paid when billed by a dentist/dental office other than the one who seated the crown or performed the previous recementation or rebonding.

Covered at the Prosthodontic level

Delta Dental Utilization Review Guidelines Page 75 1/1/21 D6093 Re-cement or re-bond a. No payment is made for recementation or rebonding of fixed partial dentures and the fees are not billable to the implant/abutment patient by a participating dentist if done within six months of the initial seating date by the same dentist/dental office. supported fixed b. Benefits may be paid for one recementation or rebonding after six months have elapsed since the initial placement. partial denture Subsequent requests for recementation or rebonding by the same dentist/dental office are DENIED. Benefits may be paid when billed by a dentist/dental office other than the one who seated the crown or performed the previous recementation or rebonding.

Covered at the Prosthodontic level D6095 Repair implant CDT: This procedure involves the repair or replacement of an implant abutment. Narrative abutment, by report

Not a covered benefit unless the subscriber's contract has an Implant Rider or single tooth implant benefit.

D6096 Remove broken a. Not a covered benefit unless the subscriber's contract has an Implant Rider or single tooth implant benefit. implant retaining b. When covered, limit once per five years (to mirror implant frequency). screw Rationale: An implant retaining screw should function properly and should remain in place for the longevity of the implant restoration.

D6199 Unspecified implant CDT: Use for an implant procedure that is not adequately described by a code. Describe procedure. Narrative procedure, by report Certain procedures may be covered if the patient has an Implant Rider. May require IC review by Dental Consultant. PROSTHODONTICS, FIXED D6200-D6999 **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.** Each retainer and each pontic constitutes a unit in a fixed partial denture. The term "fixed partial denture" or FPD is synonymous with fixed bridge or bridgework. Fixed partial denture prosthetic procedures include routine temporary prosthetics. When indicated, interim or provisional codes should be reported separately.

Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

General Policy: Fixed bridges are not a benefit for patients under age 16. FIXED PARTIAL DENTURE PONTICS D6205 Pontic - indirect resin CDT: Not to be used as a temporary or provisional prosthesis. based composite D6210 Pontic - cast high *If within the 60-month time period, the bridge is replaced with additional units, benefits will only be made for the new Tooth number and pre- noble metal units of the bridge. operative periapical x-rays showing the entire treatment site

Delta Dental Utilization Review Guidelines Page 76 1/1/21 D6211 Pontic - cast Tooth number and pre- predominantly base operative periapical x-rays metal showing the entire treatment site D6212 Pontic - cast noble Tooth number and pre- metal operative periapical x-rays showing the entire treatment site D6214 Pontic - titanium and Tooth number and pre- titanium alloys operative periapical x-rays showing the entire treatment site D6240 Pontic - porcelain Tooth number and pre- fused to high noble operative periapical x-rays metal showing the entire treatment site D6241 Pontic - porcelain Tooth number and pre- fused to operative periapical x-rays predominantly base showing the entire metal treatment site D6242 Pontic - porcelain Tooth number and pre- fused to noble metal operative periapical x-rays showing the entire treatment site D6243 Pontic - porcelain Tooth number and pre- fused to titanium and operative periapical x-rays titanium alloys showing the entire treatment site D6245 Pontic - Tooth number and pre- porcelain/ceramic operative periapical x-rays showing the entire treatment site D6250 Pontic - resin with Tooth number and pre- high noble metal operative periapical x-rays showing the entire treatment site D6251 Pontic - resin with Tooth number and pre- predominantly base operative periapical x-rays metal showing the entire treatment site D6252 Pontic - resin with Tooth number and pre- noble metal operative periapical x-rays showing the entire treatment site D6253 Provisional pontic - CDT: Not to be used as a temporary pontic for routine prosthetic fixed partial dentures. further treatment or completion of diagnosis necessary prior to final impression.

Delta Dental Utilization Review Guidelines Page 77 1/1/21 Temporary and interim fixed prostheses are not separate benefits and should be included in the fee for the permanent prosthesis. Separate fees by the same dentist/dental office are not billable to the patient by a participating dentist.

If provider submits for a temporary bridge because patient never returned for insertion, allow D6253 and D6793.

FIXED PARTIAL DENTURE RETAINERS - INLAYS/ONLAYS D6545 Retainer - cast metal Limitation: Tooth number, and pre- for resin bonded fixed Benefits are allowed once every 60 months. If within the 60 months a new bridge is made with additional units, benefits operative periapical x-rays prosthesis will only be made for the new units of the bridge. showing the entire treatment site D6548 Tooth number, and pre- porcelain/ceramic for operative periapical x-rays resin bonded fixed showing the entire prosthesis treatment site D6549 Benefits are allowed once every 60 months. If within the 60 months a new bridge is made with additional units, benefits resin bonded fixed will only be made for the new units of the bridge. prosthesis D6600 Retainer inlay - An alternate benefit of an amalgam restoration will be made toward procedures D6600 and D6601. porcelain ceramic-two surfaces D6601 Retainer inlay - An alternate benefit of an amalgam restoration will be made toward procedures D6600 and D6601. porcelain/ceramic, three or more surfaces D6602 Retainer inlay - cast An alternate benefit allowance of an amalgam restoration will be made towards the cost of all metallic inlays. Patient is high noble metal-two surfaces D6603 Retainer inlay - cast high noble metal- three or more surfaces D6604 Retainer inlay - cast predominately base metal-two surfaces D6605 Retainer inlay - cast predominately base metal-three or more surfaces D6606 Retainer inlay - cast noble metal-two surfaces D6607 Retainer inlay - cast noble metal-three or more surfaces D6608 Retainer onlay ­ Tooth number, and pre- porcelain ceramic-two operative periapical x-rays surfaces showing the entire treatment site

Delta Dental Utilization Review Guidelines Page 78 1/1/21 D6609 Retainer onlay - Tooth number, and pre- porcelain ceramic- operative periapical x-rays three or more showing the entire surfaces treatment site D6610 Retainer onlay - cast Must meet the requirements for bridge placement. Tooth number, and pre- high noble metal-two operative periapical x-rays surfaces showing the entire treatment site D6611 Retainer onlay - cast see D6610 for guidelines Tooth number, and pre- high noble metal- operative periapical x-rays three or more showing the entire surfaces treatment site D6612 Retainer onlay - cast see D6610 for guidelines Tooth number, and pre- predominantly base operative periapical x-rays metal, two surfaces showing the entire treatment site D6613 Retainer onlay - cast see D6610 for guidelines Tooth number, and pre- predominantly base operative periapical x-rays metal-three or more showing the entire surfaces treatment site D6614 Retainer onlay - cast see D6610 for guidelines Tooth number, and pre- noble metal, two operative periapical x-rays surfaces showing the entire treatment site D6615 Retainer onlay - cast see D6610 for guidelines Tooth number, and pre- noble metal, three operative periapical x-rays surfaces showing the entire treatment site D6624 Retainer inlay - An alternate benefit allowance of an amalgam restoration will be made towards the cost of a titanium inlay. Patient is titanium D6634 Retainer onlay - see D6610 for guidelines Tooth number, and pre- titanium operative periapical x-rays showing the entire treatment site FIXED PARTIAL DENTURE RETAINERS - CROWNS Only one cast restoration per tooth will be covered in a 60- month period. Cast restorations include all models, temporaries, final x-rays and other associated procedures. Benefits are payable on the insertion date. If within the 60-month time period, additional units must be added to a new bridge, benefits will only be made for the new units. D6710 Retainer crown - Not to be used as a temporary or provisional prosthesis. indirect resin based composite D6720 Retainer crown - resin Tooth number, and pre- with high noble metal operative periapical x-rays showing the entire treatment site D6721 Retainer crown ­ resin Tooth number, and pre- with predominantly operative periapical x-rays base metal showing the entire treatment site

Delta Dental Utilization Review Guidelines Page 79 1/1/21 D6722 Retainer crown - resin Tooth number, and pre- with noble metal operative periapical x-rays showing the entire treatment site D6740 Retainer crown - Tooth number, and pre- porcelain/ ceramic operative periapical x-rays showing the entire treatment site D6750 Retainer crown - Tooth number, and pre- porcelain fused to operative periapical x-rays high noble metal showing the entire treatment site D6751 Retainer crown - Tooth number, and pre- porcelain fused to operative periapical x-rays predominantly base showing the entire metal treatment site D6752 Retainer crown - Tooth number, and pre- porcelain fused to operative periapical x-rays noble metal showing the entire treatment site D6753 Retainer crown - Tooth number, and pre- porcelain fused to operative periapical x-rays titanium and titanium showing the entire alloys treatment site D6780 Retainer crown - 3/4 Tooth number, and pre- cast high noble metal operative periapical x-rays showing the entire treatment site D6781 Retainer crown - 3/4 Tooth number, and pre- cast predominantly operative periapical x-rays base metal showing the entire treatment site D6782 Retainer crown - 3/4 Tooth number, and pre- cast noble metal operative periapical x-rays showing the entire treatment site D6783 Retainer crown - 3/4 Tooth number, and pre- porcelain/ceramic operative periapical x-rays showing the entire treatment site D6784 Retainer crown - 3/4 Tooth number, and pre- titanium and titanium operative periapical x-rays alloys showing the entire treatment site D6790 Retainer crown - full Tooth number, and pre- cast high noble metal operative periapical x-rays showing the entire treatment site

Delta Dental Utilization Review Guidelines Page 80 1/1/21 D6791 Retainer crown - full Tooth number, and pre- cast predominantly operative periapical x-rays base metal showing the entire treatment site D6792 Retainer crown - full Tooth number, and pre- cast noble metal operative periapical x-rays showing the entire treatment site D6794 Retainer crown - Benefit same as D6790. Tooth number, and pre- titanium and titanium operative periapical x-rays alloys showing the entire treatment site D6793 Provisional retainer CDT: Not to be used as a temporary retainer crown for routine prosthetic fixed partial dentures. crown - further treatment or completion of diagnosis necessary prior to final impression Temporary or provisional fixed prostheses are not separate benefits and should be included in the fee for the permanent prosthesis. Separate fees to the same dentist/dental office are not billable to the patient by a participating dentist.

If provider submits for a temporary bridge because patient never returned for insertion, allow D6253 and D6793.

OTHER FIXED PARTIAL DENTURE SERVICES D6920 Connector bar CDT: A device attached to fixed partial denture retainer or coping that serves to stabilize and anchor a removable overdenture prosthesis. D6930 Re-cement or re-bond a. No payment is made for recementation or re-bonding of a fixed partial denture by the same dentist/dental office fixed partial denture within six months of the seating date and the fee is not billable to the patient by a participating dentist as a component of the fee for the original procedure. b. Benefits may be paid for one recementation or re-bonding after six months have elapsed since the initial placement. Subsequent requests for recementation or re-bonding by the same dentist/dental office are DENIED. Benefits may be paid when billed by a dentist/dental office other than the one who seated the bridge or performed the previous recementation or re-bonding.

D6940 Stress breaker CDT: A non-rigid connector. Pre-operative x-ray and narrative D6950 Precision attachment CDT: A male and female pair constitutes one precision attachment and is separate from the prosthesis. Tooth number, pre- operative x-ray D6980 Fixed partial denture An "overcrown" or sleeve" should be coded as a D6980. repair, necessitated May refer to the Consultant for IC to establish fee. by restorative material failure One repair (per unit) is allowed in a 60 month period. Recementation is a separate benefit.

D6985 Pediatric partial CDT: This prosthesis is used primarily for aesthetic purposes. denture - fixed DENIED unless covered by group/individual contract.

Delta Dental Utilization Review Guidelines Page 81 1/1/21 D6999 Unspecified fixed CDT: Used for procedure that is not adequately described by a code. Describe procedure. Narrative prosthodontic May require IC review by Dental Consultant. procedure, by report

60 MONTHS TIME LIMITATION ON CROWNS AND FIXED BRIDGES Replacement: Benefits are allowed for one bridge per tooth in a 60-month period. CONTRACTUAL LIMITATIONS Extra Abutments Delta Dental will benefit for replacement of missing natural teeth using the normal amount of abutments for the span. Additional abutments necessary due to special conditions or for splinting are optional and if performed, the patient will be responsible for the additional cost.

including maxillary lateral incisors, mandibular lateral incisors or mandibular central incisors. In these cases, a DOUBLE ABUTMENT will be allowed. Example: If there are two missing lower centrals, lower laterals are usually inadequate support. The cuspids on each side should be used as additional support. When there are missing upper centrals and the upper laterals appear to be inadequate supports due to small roots, (or missing centrals were extremely large), the cuspids may be needed as additional supports. These cases will be reviewed on an I.C. basis with consideration for mobility, crown/root ratio and tipping. Extra Pontics Delta Dental will only make payment for the replacement of missing natural teeth. Any pontic required because of spaces in excess of those resulting from the extraction of the normal complement of natural teeth is a special condition of that patient's mouth and the patient must be responsible for the cost necessary to replace such teeth. The patient is responsible for the entire cost of the prosthesis (3 unit bridge).

a multi-rooted tooth. c) space created from orthodontic movement Replacement of a congenitally missing tooth or impacted tooth may be benefited. The Periodontally Involved Tooth As a guideline, any tooth with only 50% of the bone remaining should be considered questionable in terms of long-term prognosis.

Posterior Fixed Bridges with Partial Dentures A posterior bridge performed in conjunction with a partial in the same arch is not a benefit. The patient is responsible up to the dentist's charge. However; an anterior bridge in conjunction with a posterior partial in the same arch is allowed.

Insufficient Pontic Space If there does not appear to be sufficient tooth space to accommodate a pontic involved in a three unit bridge, refer to the Dental Consultant. If Consultant determines there is insufficient pontic space deny entire bridge. If the bridge involves more than 2 pontics, and there is only enough space for 1 pontic, deny one of the pontics, approve other units of the bridge. A bridge fabricated for the purpose of periodontal splinting is not a covered benefit. Cantilever Bridges

Delta Dental Utilization Review Guidelines Page 82 1/1/21 General Policy - Maxillary anterior cantilever bridges listing cuspids as an abutment and replacing the lateral is a benefit. 1. On posterior cantilever bridges, only one cantilever pontic will be an allowable benefit. 2. Cantilevering a second molar pontic off of just a first molar abutment is not a benefit and is DENIED. 3. Benefits for cantilevered second molar pontics are DENIED unless unusual circumstances exist. Rationale - Allow only when unusual circumstances have been explained by treating dentist. 4. All cantilever bridges can be reviewed on an individual consideration basis independent of the above guidelines.

Cantilever bridges that include canine or premolar teeth as the cantilever pontic may be considered appropriate after Dental Consultant review. There may be enough support from the adjacent abutments to support a cantilever bridge.

Labially/Lingually Displaced Tooth (to be extracted-no pathology) & Fixed Bridge Placed If treatment is due to pathology, treatment would be allowed, yet subject to bridge guidelines. Targis/Vectris Bridges, Monodont Bridges and Other Fiber Reinforced Composite Bridges All Targis/Vectris bridges, Monodont bridges and other fiber reinforced composite bridge systems should be processed using procedure code D6999 and denied. REPLACEMENT RULES If a single crown is benefited and within 60 months (or time limitation per contract) the tooth next to it is extracted and a fixed bridge is being placed, Delta Dental will deny the abutment. The patient is responsible for the balance up to the dentist's charge. If a single crown is benefited and within 60 months (or time limitation per contract) the same tooth is extracted and is being replaced by a pontic as part of a fixed bridge, Delta Dental will deny the pontic. The patient is responsible for the balance up to the dentist's charge. (C) Bridge => New Bridge one or more of the abutments is extracted and a new bridge is being placed, only the new units will be benefited. Deny the other units. (D) Maryland Bridge => Conventional Bridge limitation per contract) is replaced with a conventional bridge, benefit the difference between the allowance for the conventional bridge abutments and amount paid for the Maryland Bridge retainers. The patient is responsible for the balance up to the dentist's allowance (participating dentist) or charge (non-participating dentist) for the replacement unit(s). Deny pontic(s). (E) Bridge => Partial

(F) Partial => Bridge are being replaced with a bridge, deny the bridge. charge.

If a partial is paid and within 60 months (or time limitation per contract) the same tooth is being replaced with a crown over the implant (D6059- D6084 and D6094), deny the crown over the implant. The patient is responsible for the balance up to the

(H) Onlay => Crown is being replaced with a single tooth crown, deny the crown. The patient is responsible for the balance up to the

No exceptions will be provided for the following:

Delta Dental Utilization Review Guidelines Page 83 1/1/21 Partial => Complete Denture - Deny. 3/4 Crown => Full Crown - Deny. Crown/Pontic => Crown over Implant - Deny. MISSING TOOTH EXCLUSION Some subscriber contracts have a missing tooth exclusion. The specific terms of when to apply the exclusion varies by contract. The missing tooth exclusion will apply if the tooth being replaced was missing prior to the date the patient's effective date of coverage. The three (3) basic types of exclusions are as follows: 1) Reduced Benefit 2) No Benefit 3) Waiting Period: waiting period for the replacement of teeth missing prior to effective date of coverage ORAL AND MAXILLOFACIAL SURGERY D7000-D7999 Benefit allowance includes local anesthesia and routine post­operative care For dental benefit reporting purposes a quadrant is defined as four or more contiguous teeth and/or teeth spaces distal to the midline. Extractions (Includes Local Anesthesia, Suturing, If Needed And Routine Postoperative Care)

Unsuccessful extractions - A claim should not be filed for an extraction if the entire tooth is not removed. The claim should be filed by the dentist who successfully extracted the tooth.

The fee for an extraction includes up to three (3) post-operative visits (dry socket). Each additional treatment of a dry socket is benefited as a palliative treatment. Not a covered benefit. DENIED unless covered by group/individual contract.

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

Benefits for platelets (D9999) are denied as investigational. Maxillofacial Surgery (D7111-D7999 except D7880, D7881, D7990, and D7997) General Policy - No payment is made for biopsy (D7285, D7286), frenulectomy (D7961, D7962) and excision of hard and soft tissue lesions (D7410, D7411, D7450, D7451) and the fees are not billable to the patient by a participating dentist. Requests for individual consideration can be submitted by report for dental consultant review when the procedures are performed on the same date, same surgical site/area, by the same dentist/dental office as the above referenced codes.

conventional methods are adequate. **See Benefit Check for contract specific information regarding medical prime procedures.

D7111 Extraction, coronal CDT: Removal of soft tissue-retained coronal remnants. remnants - primary tooth Considered part of any other primary surgery in the same site, by the same dentist, on the same day. D7140 Extraction, erupted CDT: Includes removal of tooth structure, minor smoothing of socket bone and closure, as necessary. tooth or exposed root Benefit allowance includes local anesthesia and routine post­operative care (i.e. dry socket). (elevation and/or forceps removal)

Delta Dental Utilization Review Guidelines Page 84 1/1/21 Images must be less than 2 years old, of diagnostic quality; properly oriented if submitted for documentation purposes, and with the date of exposure and a patient identifier indicated on all images. If image is not of diagnostic quality, no payment is made and the fee for the image is not billable to the patient by a participating dentist.

D7210 Extraction, erupted CDT: Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and Tooth number and pre- tooth requiring closure. operative periapical x-ray removal of bone and/or sectioning of Pre-operative x-rays are required for benefit consideration. Benefits are allowed based on the anatomical position of the tooth, and including tooth and not on the degree of difficulty. Benefit allowance includes sutures, local anesthesia and routine post-operative elevation of care (i.e.: dry socket). When a patients coverage is for a simple extraction only, an allowance will be made towards the mucoperiosteal flap if surgical extraction. The patient is responsible for the difference up to the dentist's charge. indicated D7220 Removal of impacted CDT: Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. Tooth number and pre- tooth - soft tissue operative periapical x-ray

D7230 **Removal of CDT: Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Tooth number and pre- impacted tooth - operative periapical x-ray partially bony D7240 **Removal of CDT: Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Tooth number and pre- impacted tooth - operative periapical x-ray complete bony D7241 **Removal of CDT: Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection Tooth number and pre- impacted tooth - required, separate closure of required or aberrant tooth position. operative periapical x-ray complete bony, with and detailed narrative unusual surgical complications D7250 Removal of residual CDT: Includes cutting of soft tissue and bone, removal of tooth structure, and closure. Tooth number and pre- roots (cutting CDT definition of residual root: Remaining root structure following the loss of the major portion (over 75%) of the crown. operative periapical x-ray procedure) No benefits are allowed for root recovery in addition to the extraction when performed by the same dentist/dental office.

D7251 Coronectomy- CDT: Intentional partial tooth removal is performed when a neurovascular complication is likely if the entire impacted Tooth number, pre and intentional partial tooth is removed. post operative periapical x- tooth removal rays, treatment notes and detailed narrative indicating the reason why the procedure was intentionally performed Benefited under individual consideration and only for documented probable neurovascular complications as proximity to mental foramen, inferior alveolar nerve, sinus, etc. Benefit only under group/individual contracts that cover removal of impacted teeth. Note: enhanced complexity due to angulation of the cuts to remove the crown and not disturb the roots (mobilize). *All third molars do not qualify as surgical extractions. Each case will be considered individually and based on anatomical position. Criteria for Surgical Extractions: D7210) Includes cutting gingiva and bone, removal of bone and/or tooth and closure. D7220) Not fully erupted, but tooth may be removed with a soft tissue flap and no bone removal. D7230) Part of crown covered by bone: Bone interfering with removal of tooth requiring removal of some bone and mucoperiosteal flap elevation.

D7240) Bone covering most (> 75%) or all of the crown - requiring mucoperiosteal flap elevation and bone removal.

Delta Dental Utilization Review Guidelines Page 85 1/1/21 D7241) Submission must have narrative describing surgical complications. Definitive list of criteria should include: 1. Radiographic evidence of thick, dense bone which makes elevation of exposure of the tooth difficult. This would include (in narrative) mention of exostosis buccal or palatal, complicating the removal. 2. Radiographic evidence of pathologic conditions such as cysts or tumors which may displace impacted teeth making access extremely difficult and necessitating removal through the sinus or other anatomic structures. 3. Relationship to adjacent teeth. A third molar may be positioned near the apical third of adjacent teeth, necessitating removal through the lateral maxillary sinus wall. Fusion of the third molars to adjacent teeth occasionally occurs necessitating removal of both teeth or sectioning one tooth from another. 4. Relationship to the maxillary sinus, inferior alveolar nerve or nasal cavity requiring modifications of incisions and approach to gain access for removal. 5. Radiographic evidence of ectopic positioning of third molars requiring complicated techniques for removal. 6. Radiographic evidence of dilacerations of roots. The documentation for review should include a narrative detailing the unusual nature of the procedure and radiographs showing evidence of one or more of the criteria above. Mention needs to be made to sectioning of a tooth; relationship is important to anatomic structures, i.e., nerves, sinus, nasal cavity, infratemporal fossa, etc., and the position of the tooth, i.e., distoangular, inverted, or lingual/palatal/buccal (sideways). If an extraction is submitted without the required pre-operative x-ray, the claim is processed requesting an x-ray. If the dentist submits a narrative indicating why he/she did not take, or is unable to locate, the pre-operative x-ray, the claim will be reviewed on an IC basis and paid as a simple extraction. The code will be changed to reflect a simple extraction D7140. In order to appeal this decision, a current (less than two years old) pre-operative x-ray of diagnostic quality showing the entire treatment site is required.

OTHER SURGICAL PROCEDURES **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.** **See Benefit Check for contract specific information regarding medical prime procedures. D7260 **Oroantral fistula CDT: Excision of fistulous tract between maxillary sinus and oral cavity and closure by advancement flap. closure D7261 **Primary closure of a CDT: Subsequent to surgical removal of tooth, exposure of sinus requiring repair or immediate closure of oroantral or sinus perforation oralnasal communication in absence of fistulous tract. No payment is made for D7261 when submitted with D7241 and the fees are not billable to the patient by a participating dentist. D7270 Tooth reimplantation CDT: Includes splinting and/or stabilization. and/or stabilization of accidentally evulsed or displaced tooth

D7272 Tooth transplantation DENIED unless covered by group/individual contract. (includes reimplantation from one site to another and splinting and/or stabilization)

D7280 Exposure of an CDT: An incision is made and the tissue is reflected and bone removed as necessary to expose the crown of an impacted unerupted tooth tooth not intended to be extracted.

Delta Dental Utilization Review Guidelines Page 86 1/1/21 D7282 Mobilization of CDT: To move/luxate teeth to eliminate ankylosis; not in conjunction with an extraction. erupted or malpositioned tooth to aid eruption No payment is made for D7282 when performed by the same dentist/dental office in conjunction with other surgery (D7000 oral surgery series, D4210-D4276 periodontal surgery) in the immediate area, and the fee is not billable to the patient by a participating dentist. D7283 Placement of device CDT: Placement of an attachment on an unerupted tooth after its exposure, to aid in its eruption. Report the surgical to facilitate eruption exposure separately using D7280. of impacted tooth D7285 **Incisional biopsy of CDT: For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is not used for oral tissue - hard apicoectomy/periradicular surgery. This procedure does not entail an excision. (bone, tooth) a. A pathology report must be included. b. The fee for biopsy of oral tissue is not billable to the patient by a participating dentist as it is included in the fee for a surgical procedure (e.g. apicoectomy, extractions, etc.) when performed by the same dentist/dental office in the same surgical area and on the same date of service. c. Biopsy is only payable for oral structures.

D7286 **Incisional biopsy of CDT: For partial removal of an architecturally intact specimen only. This procedure is not used at the same time as codes oral tissue - soft for apicoectomy/periradicular curettage. This procedure does not entail an excision. a. A pathology report must be included. b. The fee for biopsy of oral tissue is not billable to the patient by a participating dentist as it is included in the fee for a surgical procedure (e.g. apicoectomy, extractions, etc.) when performed by the same dentist/dental office in the same surgical area and on the same date of service. c. Biopsy is only payable for oral structures.

D7287 Exfoliative cytology CDT: For collection of non-transepithelial cytology sample via mild scraping of the oral mucosa. sample collection D7288 Brush CDT: For collection of oral disaggregated transepithelial cells via rotational brushing of the oral mucosa. biopsy­transepithelial sample collection D7290 Surgical repositioning CDT: Grafting procedure(s) is/are additional. of teeth DENIED unless covered by group/individual contract.

D7291 Transseptal CDT: The supraosseous connective tissue attachment is surgically severed around the involved teeth. Where there are fiberotomy/supra adjacent teeth, the transseptal fiberotomy of a single tooth will involve a minimum of three teeth. Since the incisions are crestal fiberotomy, by within the and tissue and the root surface is not instrumented, this procedure heals by the reunion of report connective tissue with the root surface on which viable periodontal tissue is present (reattachment). DENIED unless covered by group/individual contract.

D7292 Placement of DENIED unless covered by group/individual contract. temporary anchorage device [screw retained plate] requiring flap; includes device removal

Delta Dental Utilization Review Guidelines Page 87 1/1/21 D7293 Placement of DENIED unless covered by group/individual contract. temporary anchorage device requiring flap; includes device removal

D7294 Placement of DENIED unless covered by group/individual contract. temporary anchorage device without flap; includes device removal

D7295 Harvest of bone for CDT: Reported in addition to those autogenous graft placement procedures that do not include harvesting of bone. use in autogenous DENIED unless covered by group/individual contract. grafting procedure Allow if D7953 bone replacement graft for ridge preservation - per site is covered. When performed, this should be reported in addition to those autogenous graft placement procedures that do not include harvesting of bone (D7953 and D7955).

D7296 CDT: This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the three teeth or tooth jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and spaces, per quadrant closure. Graft material and membrane, if used, should be reported separately.

Benefits for corticotomy procedures are DENIED as a specialized procedure. D7297 CDT: This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or basal bone of the more teeth or tooth jaw for the purpose of facilitating orthodontic repositioning of the dentition. This procedure includes flap entry and spaces, per quadrant closure. Graft material and membrane, if used, should be reported separately.

Benefits for corticotomy procedures are DENIED as a specialized procedure. ALVEOLOPLASTY - PREPARATION OF RIDGE Pre-treatment estimate is recommended. Benefit allowance includes sutures, local anesthesia and routine post-operative care. Benefits are allowed once in a 60 month period. D7310 Alveoloplasty in CDT: The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a prosthesis or other Quadrant identification/ conjunction with treatments such as radiation therapy and transplant surgery. treatment site(s), pre- extractions - four or operative x-rays more teeth or tooth spaces, per quadrant a. Alveoloplasty is included in the fee for extractions (D7140, D7210-D7250). Fees for these procedures are not billable to the patient by a participating dentist if performed by the same dentist/dental office, in the same surgical area on the same date. b. Fees are not billable to the patient by a participating dentist no matter how many extractions are performed in the quadrant. D7311 Alveoloplasty in CDT: The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a prosthesis or other Quadrant identification/ conjunction with treatments such as radiation therapy and transplant surgery. treatment site(s), pre- extractions -one to operative x-rays three teeth or tooth spaces, per quadrant

Delta Dental Utilization Review Guidelines Page 88 1/1/21 a. Alveoloplasty is included in the fee for extractions (D7140, D7210-D7250). Fees for these procedures are not billable to the patient by a participating dentist if performed by the same dentist/dental office, in the same surgical area on the same date. b. Fees are not billable to the patient by a participating dentist no matter how many extractions are performed in the quadrant. D7320 Alveoloplasty not in CDT: No extractions performed in an edentulous area. See D7310 if teeth are being extracted concurrently with the Quadrant identification/ conjunction with alveoloplasty. Usually in preparation for a prosthesis or other treatments such as radiation therapy and transplant treatment site(s), pre- extractions - four or surgery. operative x-rays more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in CDT: No extractions performed in an edentulous area. See D7310 if teeth are being extracted concurrently with the Quadrant identification/ conjunction with alveoloplasty. Usually in preparation for a prosthesis or other treatments such as radiation therapy and transplant treatment site(s), pre- extractions - one to surgery. operative x-rays three teeth or tooth spaces, per quadrant VESTIBULOPLASTY Any of a series of surgical procedures designed to increase relative alveolar ridge height. D7340 **Vestibuloplasty­ridg Benefit allowance includes sutures, local anesthesia and routine post-operative care. Benefits are allowed once in a 60 Quadrant or arch e extension month period. identification/ treatment (secondary site(s), pre-operative x- epithelization) rays D7350 **Vestibuloplasty - Quadrant or arch ridge extension identification/ treatment (including soft tissue site(s), pre-operative x- grafts, muscle rays reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) EXCISION OF SOFT TISSUE LESIONS Benefit allowance includes local anesthesia and routine post­operative care D7410 **Excision of benign lesion up to 1.25 cm D7411 **Excision of benign lesion greater than 1.25 cm D7412 ** Excision of benign CDT: Requires extensive undermining with advancement or rotational flap closure lesion, complicated

D7413 **Excision of malignant lesion up to 1.25 cm D7414 ** Excision of malignant lesion greater than 1.25 cm

Delta Dental Utilization Review Guidelines Page 89 1/1/21 D7415 **Excision of CDT: Requires extensive undermining with advancement or rotational flap closure. malignant lesion, complicated EXCISION OF INTRA-OSSEOUS LESIONS D7440 ** Excision of malignant tumor - lesion diameter up to 1.25 cm D7441 ** Excision of Pathology report, & malignant tumor - narrative lesion diameter greater than 1.25 cm D7450 ** Removal of benign or tumor - lesion diameter up to 1.25cm

D7451 ** Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25cm D7460 **Removal of benign non- odontogenic cyst or tumor-lesion diameter up to 1.25cm

D7461 ** Removal of benign non- odontogenic cyst or tumor-lesion diameter greater than 1.25cm

D7465 Destruction of CDT: Examples include using cryo, laser or electro surgery. lesion(s) by physical DENIED unless covered by group/individual contract. or chemical method, by report

EXCISION OF BONE TISSUE D7471 **Removal of lateral Procedures include removal of tori, tuberosity and other protuberances. exostosis (maxilla or mandible) D7472 **Removal of D7473 **Removal of D7485 **Reduction of osseous tuberosity

Delta Dental Utilization Review Guidelines Page 90 1/1/21 D7490 Radical resection of CDT: Partial resection of maxilla or mandible; removal of lesion and defect with margin of normal appearing bone. mandible with bone Reconstruction and bone grafts should be reported separately. graft DENIED unless covered by group/individual contract. SURGICAL INCISION D7510 Incision and drainage CDT: Involves incision through mucosa, including periodontal origins. of - intraoral Incision and drainage requires incision with a blade and placement of a drain and suture. soft tissue Incision and drainage is NOT intended for gingival curettage of a (use D9110, palliative treatment).

Surgical incision is included in the fee for endodontics, extractions, palliative treatment or other definitive services done on the same date of service by the same dentist/dental office. Fees for incision and drainage of abscess are not billable to the patient by a participating dentist when submitted with all oral surgery (D7000-D7999) and endodontic codes (D3000-D3999) and surgical periodontal procedures (D4210-D4278). D7511 Incision and drainage CDT: Incision is made intraorally and dissection is extended into adjacent fascial space(s) to provide adequate drainage of abscess-intraoral of abscess/. soft tissue- complicated (includes drainage of multiple fascial spaces)

Fees for D7511 are not billable to the patient by a participating dentist/dental office on the same date of service with all oral surgery (D7000-D7999) and endodontic codes (D3000 - D3999).

D7520 **Incision and CDT: Involves incision through skin. drainage of abscess - Incision and drainage requires incision with a blade and placement of a drain and suture. extraoral soft tissue

D7521 **Incision and CDT: Incision is made extraorally and dissection is extended into adjacent fascial space(s) to provide adequate drainage drainage of abscess- of abscess/cellulitis. extraoral soft tissue- complicated (includes drainage of multiple fascial spaces)

D7530 Removal of foreign DENIED unless covered by group/individual contract. body from mucosa, skin, or sub cutaneous alveolar tissue

D7540 Removal of reaction CDT: May include, but is not limited to, removal of splinters, pieces of wire, etc., from muscle and/or bone. producing foreign DENIED unless covered by group/individual contract. bodies, musculoskeletal system

D7550 **Partial CDT: Removal of loose or sloughed-off dead bone caused by infection or reduced blood supply. ostectomy/seque strectomy for removal of non-vital bone

Delta Dental Utilization Review Guidelines Page 91 1/1/21 D7560 Maxillary sinusotomy DENIED unless covered by group/individual contract. for removal of tooth fragment or foreign body

TREATMENT OF CLOSED FRACTURES No payment is made for splinting, wiring or banding and the fee is not billable to the patient by a participating dentist when performed by the same dentist/dental office rendering the primary procedure. D7610 **Maxilla - open CDT: Teeth may be wired, banded or splinted together to prevent movement. Incision required for interosseous fixation. reduction (teeth immobilized, if present) D7620 **Maxilla-closed CDT: No incision required to reduce fracture. See D7610 if interosseous fixation is applied. reduction (teeth immobilized if present) D7630 **Mandible-open CDT: Teeth may be wired, banded or splinted together to prevent movement. Incision required to reduce fracture. reduction (teeth immobilized if present) D7640 **Mandible-closed CDT: No incision required to reduce fracture. See D7630 if interosseous fixation is applied. reduction (teeth immobilized if present) D7650 **Malar and/or zygomatic arch - open reduction D7660 **Malar and/or zygomatic arch - closed reduction D7670 **Alveolus - closed CDT: Teeth may be wired, banded or splinted together to prevent movement. reduction, may include stabilization of teeth D7671 **Alveolus-open CDT: Teeth may be wired, banded or splinted together to prevent movement. reduction, may include stabilization of teeth D7680 Facial - CDT: Facial bones include upper and lower jaw, cheek and bones around eyes, nose and ears. complicated reduction DENIED unless covered by group/individual contract. with fixation and multiple surgical approaches TREATMENT OF OPEN FRACTURES No payment is made for splinting, wiring or banding and the fee is not billable to the patient by a participating dentist when performed by the same dentist/dental office rendering the primary procedure. D7710 **Maxilla - open CDT: Incision required to reduce fracture. reduction D7720 **Maxilla - closed reduction

Delta Dental Utilization Review Guidelines Page 92 1/1/21 D7730 **Mandible - open CDT: Incision required to reduce fracture. reduction D7740 **Mandible closed reduction D7750 **Malar and/or CDT: Incision required to reduce fracture. zygomatic arch - open reduction D7760 **Malar and/or zygomatic arch - closed reduction D7770 **Alveolus - open CDT: Fractured bone(s) are exposed to mouth or outside the face. Incision required to reduce fracture. reduction stabilization of teeth

D7771 **Alveolus - closed reduction stabilization of teeth D7780 Facial bones - CDT: Incision required to reduce fracture. Facial bones include upper and lower jaw, cheek and bones around eyes, nose complicated reduction and ears. with fixation and DENIED unless covered by group/individual contract. multiple approaches

REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS Procedures that are an integral part of a primary procedure should not be reported separately. TMJ Rider Codes (D7810, D7820, D7830, D7871, D7880, D7881, D9942, D9950, D9951, D9952) D7810 **Open reduction of CDT: Access to TMJ via surgical opening. dislocation Not a covered benefit unless the subscriber's contract has a TMJ rider. D7820 **Closed reduction of CDT: Joint manipulated into place; no surgical exposure. dislocation Not a covered benefit unless the subscriber's contract has a TMJ rider. D7830 **Manipulation under CDT: Usually done under general anesthesia or intravenous sedation. anesthesia Not a covered benefit unless the subscriber's contract has a TMJ rider. Procedure codes D7840-D7870, D7872-D7877 and D7899 are DENIED unless covered by group/individual contract. D7840 Condylectomy CDT: Removal of all or portion of the mandibular condyle (separate procedure). D7850 Surgical discectomy, CDT: Excision of the intra-articular disc of a joint. with/without implant

D7852 Disc repair CDT: Repositioning and/or sculpting of disc; repair of perforated posterior attachment. D7854 Synovectomy CDT: Excision of a portion or all of the synovial membrane of a joint. D7856 Myotomy CDT: Cutting of muscle for therapeutic purposes (separate procedure). D7858 Joint reconstruction CDT: Reconstruction of osseous components including or excluding soft tissues of the joint with autogenous, homologous, or alloplastic materials. D7860 Arthrotomy CDT: Cutting into joint (separate procedure). D7865 Arthroplasty CDT: Reduction of osseous components of the joint to create a pseudarthrosis or eliminate an irregular remodeling pattern (osteophytes). D7870 Arthrocentesis CDT: Withdrawal of fluid from a joint space by aspiration. D7871 Non-arthroscopic lysis CDT: Inflow and outflow catheters are placed into the joint space. The joint is lavaged and manipulated as indicated in an and lavage effort to release minor adhesions and synovial vacuum phenomenon as well as to remove inflammation products from the joint space. The benefits for these services are DENIED unless the related TMJ services are covered under the group/individual contract.

Delta Dental Utilization Review Guidelines Page 93 1/1/21 D7872 Arthroscopy- diagnosis, with or without biopsy D7873 Arthroscopy: lavage CDT: Removal of adhesions using the arthroscope and lavage of the joint cavities. and lysis of adhesions

D7874 Arthroscopy: disc CDT: Repositioning and stabilization of disc using arthroscopic techniques. repositioning and stabilization D7875 Arthroscopy: CDT: Removal of inflamed and hyperplastic synovium (partial/complete) via an arthroscopic technique. synovectomy D7876 Arthroscopy: CDT: Removal of disc and remodeled posterior attachment via the arthroscope. discectomy D7877 Arthroscopy: CDT: Removal of pathologic hard and/or soft tissue using the arthroscope. debridement D7880 Occlusal orthotic CDT: Presently includes splints provided for treatment of temporomandibular joint dysfunction. device, by report Not a covered benefit unless the subscriber's contract has a TMJ rider. D7881 Occlusal orthotic Benefits for occlusal orthotic devise adjustments are DENIED unless the subscriber's contract has a TMJ rider. device adjustment a. When covered by group/individual contract no payment is made for all adjustments within 6 months and the fees are not billable to the patient by a participating dentist. b. Benefit one per year following six months from initial placement. D7899 Unspecified TMD CDT: Used for procedure that is not adequately described by a code. Describe procedure. Narrative therapy, by report May require IC review by Dental Consultant. REPAIR OF TRAUMATIC WOUNDS Excludes closure of surgical incisions D7910 **Suture of recent No payment is made when performed in conjunction with D7000 series and the fee is not billable to the patient by a small wounds up to participating dentist. 5cm COMPLICATED SUTURING D7911 Complicated suture - No payment is made when performed in conjunction with D7000 series and the fee is not billable to the patient by a up to 5 cm participating dentist. D7912 Complicated suture - No payment is made when performed in conjunction with D7000 series and the fee is not billable to the patient by a greater than 5 cm participating dentist. OTHER REPAIR PROCEDURES Procedure codes D7920 through D7952: DENIED unless covered by group/individual contract. D7920 Skin graft (identify defect covered, location and type of graft) D7921 Collection and application of autologous blood concentrate product D7922 Placement of intra- CDT: This procedure can be performed at time and/or after extraction to aid in hemostasis. The socket is packed with a socket biological hemostatic agent to aid in hemostasis and/or clot stabilization. dressing to aid in hemostasis or clot stabilization, per site

Delta Dental Utilization Review Guidelines Page 94 1/1/21 a. Placement of an intra-socket biological dressing to aid in hemostasis or clot stabilization is considered part of the extraction and/or post-operative procedure. b. A separate fee is not billable to the patient by a participating dentist. D7940 Osteoplasty - for CDT: Reconstruction of jaws for correction of congenital, developmental or acquired traumatic or surgical deformity. orthognathic deformities D7941 Osteotomy - mandibular rami D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft

D7944 Osteotomy - CDT: Report by range of tooth numbers within segment. segmented or subapical D7945 Osteotomy - body of CDT: Sectioning of lower jaw. This includes exposure, bone cut, fixation, routine wound closure and normal post- mandible operative follow-up care. D7946 Lefort I (maxilla - CDT: Sectioning of the upper jaw. This includes exposure, bone cuts, downfracture, repositioning, fixation, routine wound total) closure and normal post-operative follow-up care. D7947 Lefort I (maxilla - CDT: When reporting a surgically assisted palatal expansion without downfracture, this code would entail a reduced segmented) service and should be "by report." D7948 Lefort II or Lefort III CDT: Sectioning of upper jaw. This includes exposure, bone cuts, downfracture, segmentation of maxilla, repositioning, (osteoplasty of facial fixation, routine wound closure and normal post-operative follow-up care. bones for midface hypoplasia or retrusion) - without bone graft D7949 Lefort II or Lefort III - CDT: Includes obtaining autografts. with bone graft D7950 Osseous, CDT: This procedure is for ridge augmentation or reconstruction to increase height, width and/or volume or residual osteoperiosteal, or alveolar ridge. It includes obtaining graft material. Placement of a barrier membrane, if used, should be reported cartilage graft of the separately. mandible or maxilla- autogenous or nonautogenous, by report a. Subject to coverage available under the medical plan. b. When billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc., benefits for D7950 are DENIED as a specialized procedure. c. Benefits for platelets are DENIED as investigational.

D7951 Sinus augmentation CDT: The augmentation of the sinus cavity to increase alveolar height for reconstruction of edentulous portions of the with bone or bone maxilla. This procedure is performed via a lateral open approach. This includes obtaining the bone or bone substitutes. substitutes via a Placement of a barrier membrane, if used, should be reported separately. lateral open approach.

Delta Dental Utilization Review Guidelines Page 95 1/1/21 a. Subject to coverage available under the medical plan. b. When billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc., benefits for D7951 are DENIED as a specialized procedure. c. Benefits for platelets are DENIED as investigational. D7952 Sinus augmentation CDT: The augmentation of the sinus to increase alveolar height by vertical access through the ridge crest by raising the via a vertical floor of the sinus and grafting as necessary. This includes obtaining the bone or bone substitutes. approach a. Subject to coverage available under the medical plan. b. When billed in conjunction with implants, ridge augmentation, extraction sites, periradicular surgery, etc., benefits for D7952 are DENIED as a specialized procedure. c. Benefits for platelets are DENIED as investigational.

D7953 Bone replacement CDT: Graft is placed in an extraction or implant removal site at the time of the extraction or removal to preserve ridge graft for ridge integrity (e.g. clinically indicated in preparation for implant reconstruction or where alveolar contour is critical to planned preservation - per site prosthetic reconstruction). Does not include obtaining graft material. Membrane, if used, should be reported separately.

D7955 Repair of maxillofacial CDT: Reconstruction of surgical, traumatic, or congenital defects of the facial bones, including the mandible, may utilize soft and/or hard graft materials in conjunction with soft tissue procedures to repair and restore the facial bones to form and function. This tissue defect does not include obtaining the graft and these procedures may require multiple surgical approaches. This procedure does not include edentulous maxilla and mandibular reconstruction for prosthetic considerations. DENIED unless covered by group/individual contract.

**D7961 Buccal / labial No payment is made for frenulectomy and the fee is not billable to the patient by a participating dentist when billed in frenectomy conjunction with other surgical procedure(s) (D7000-D7877, D7920-D7983, D7991-D7996, D4210- D4285 and D3410- (frenulectomy) D3470) in the same surgical area by the same dentist. **D7962 Lingual frenectomy No payment is made for frenulectomy and the fee is not billable to the patient by a participating dentist when billed in (frenulectomy) conjunction with other surgical procedure(s) (D7000-D7877, D7920-D7983, D7991-D7996, D4210- D4285 and D3410- D3470) in the same surgical area by the same dentist. D7963 **Frenuloplasty CDT: Excision of frenum with accompanying excision or repositioning of aberrant muscle and z-plasty or other local flap Tooth number closure. No payment is made for frenuloplasty and the fee is not billable to the patient by a participating dentist when billed in conjunction with other surgical procedure(s) (D7000-D7877, D7920-D7983, D7991-D7996, D4210-D4285 and D3410- D3470) in the same surgical area by the same dentist/dental office. D7970 **Excision of This procedure is included in the fee for other surgical procedures that are performed on the same day in the same area. Narrative (only if no other hyperplastic tissue - procedures done on the per arch same day) No payment is made for excision of hyperplastic tissue per arch and the fee is not billable to the patient by a participating dentist when billed in conjunction with other surgical procedure(s) (D7000-D7877, D7920-D7983, D7991- D7996, D4210-D4285 and D3410-D3470) in the same surgical area by the same dentist/dental office.

D7971 Excision of CDT: Removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted teeth. pericoronal gingiva No payment is made for excision of pericoronal gingival and the fee is not billable to the patient by a participating dentist when billed in conjunction with other surgical procedure(s) (D7000-D7877, D7920-D7983, D7991-D7996, D4210- D4276 and D3410-D3470) in the same surgical area by the same dentist/dental office.

Procedure codes D7972 through D7998: DENIED unless covered by group/individual contract. D7972 Surgical reduction of fibrous tuberosity

Delta Dental Utilization Review Guidelines Page 96 1/1/21 D7979 CDT: A sialolith is removed from the gland or ductal portion of the gland without surgical incision into the gland or the sialolithotomy duct of the gland; for example via manual manipulation, ductal dilation, or any other non-surgical method.

D7980 Surgical salolithotomy CDT: Procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.

D7981 Excision of salivary gland, by report D7982 Sialodochoplasty CDT: Procedure for the repair of a defect and/or restoration of a portion of a salivary gland duct. D7983 Closure of salivary CDT: Closure of an opening between a salivary duct and/or gland and the cutaneous surface, or an opening into the oral fistula cavity through other than the normal anatomic pathway. D7990 Emergency CDT: Formation of a tracheal opening usually below the cricoid cartilage to allow for respiratory exchange. tracheotomy D7991 Coronoidectomy CDT: Removal of the coronoid process of the mandible. D7993 Surgical placement of CDT: Surgical placement of a craniofacial implant to aid in retention of an auricular, nasal, or orbital prosthesis.

extra oral Medical coverage may include this procedure.

Benefits are DENIED unless covered by the group/individual contract.

D7994 Surgical placement: CDT: An implant placed in the zygomatic bone and exiting though the maxillary mucosal tissue providing support and zygomatic implant attachment of a maxillary dental prosthesis. Medical coverage may include this procedure.

Benefits are DENIED unless covered by the group/individual contract.

D7995 Synthetic graft - CDT: Includes allogenic material. mandible or facial bones, by report D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar D7998 Intraoral placement of CDT: The placement of intermaxillary fixation appliance for documented medically accepted treatments not in a fixation device not association with fractures. in conjunction with a fracture D7999 Unspecified oral CDT: Used for a procedure that is not adequately described by a code. Describe procedure. Narrative surgery procedure, by May require IC review by Dental Consultant. report ORTHODONTICS D8000-D8999 Benefits for orthodontics are only available when performed by a licensed dentist.

Delta Dental Utilization Review Guidelines Page 97 1/1/21 A pre-treatment estimate is recommended for all orthodontic treatment plans. The fee for orthodontic treatment includes appliances, post­treatment stabilization, etc. No payment is made for laser disinfection and the fee is not billable to the patient by a participating dentist. Laser disinfection as a stand alone procedure is denied as investigational. General Policy - No payment is made for low level laser therapy when performed as part of another procedure and the fee is not billable to the patient by a participating dentist. When billed as a stand alone procedure, low level laser therapy is denied as investigational.

Administration of Monthly Orthodontic Benefit Monthly payments, made quarterly, are payable beginning with the banding date. Upon banding, an initial payment of 30% of the patient's orthodontic maximum is made. (Prior to 01/01/04 initial payment was 25%). The initial payment is deducted from the patient's orthodontic maximum and then divided by the number of treatment months to calculate a monthly payment. Example: Orthodontic Benefit = $1200 24 month treatment plan Date of banding: Delta pays initial pmt. of $360. ($1200 x 30% = $360) Monthly payments calculated as follows: $1,200 - $360 = $840 ÷ 24 months = $35 monthly payment Rationale: Delta pays the initial payment (IP) and the first monthly payment on the date of banding. The second and third months are paid 62 days later. The next three months are paid 92 days later. Subsequent quarterly payments are made every 92 days.

For takeover business Cases in progress will be calculated as a new case: 30% initial payment. The initial payment is deducted from the patient's orthodontic maximum and then divided by the number of treatment months to calculate a monthly payment. Payment is made for the remaining months of treatment.

Example: $1500 max/24 months of treatment. IP = $450. $1500 minus $450 = $1050 $1050 divided by 24 months of treatment = $43.75/month. Member has 18 months of treatment left; DD will pay $43.75 for 18 months. Total amount DD will pay in this case = $787.50

For new business with no prior coverage for orthodontics or subscribers adding orthodontics Cases in progress will be prorated as follows: · Delta calculates the case as if the patient had coverage at time of banding, then subtracts the IP and the ineligible months. Example: Delta orthodontic benefit = $1,200. Patient completed 6 months of a 24-month treatment plan before coverage went into effect. Delta calculates as follows: $1,200 orthodontic benefit less $360 initial payment for banding (30% of orthodontic benefit) = $840 divided by 24 months for a monthly payment of $35 over a 24-month period. 6 months no coverage times $35 = $210. Ineligible amount $360 + 210 = $570. $1,200 - $570 = $630 paid quarterly over the remaining 18 months ($35 per month) Timely Filing

Delta Dental Utilization Review Guidelines Page 98 1/1/21 Every monthly payment is considered a new claim. If a patient is banded on 7/1/18 and the claim is received on 9/1/19,we will consider eligible months from 9/1/19. The patient is not eligible for an initial payment.

Example: Date of banding 7/1/2018 Claim filing receipt date 9/1/2019 Length of treatment 24 months Orthodontic Maximum $1200.00 Initial payment (30% of $1200) = $360~~~ Monthly payments ($1200 - $360 = $840) over 24 months =$35 per month

Delta will pay monthly benefits (quarterly) from 2019 through the remaining 22 months of treatment @ $35 each. The Initial Payment and the 1st and 2nd months are not eligible for benefits. Required Documentation All orthodontic claims should contain the following information: 1. Procedure code 2. Months of treatment 3. Total case fee 4. Date of banding General Limitations Post-treatment stabilization (retainers) is not a separately paid benefit. If submitted by the same dental office, it is included in the fee for the comprehensive treatment. If submitted by a different dental office and the patient has benefits available in their orthodontic maximum - allow. Custom made orthodontic A custom made orthodontic functional appliance is not included in the total case fee and can be billed separately (may functional appliances i.e.: be billed as D8220). Cemented, Hebst, MARA, M2M, etc.

Primary Dentition: Teeth developed and erupted first in order of time. Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines are in the process of shedding and the permanent successors are emerging. Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth that would affect orthodontic treatment. Adult Dentition: The dentition that is present after the cessation of growth that would affect orthodontic treatment. All of the following orthodontic treatment codes may be used more than once for the treatment of a particular patient depending on the particular circumstance. A patient may require more than one interceptive procedure or more than one limited procedure depending on their particular problem.

LIMITED ORTHODONTIC TREATMENT CDT: Orthodontic treatment with a limited objective, not necessarily involving the entire dentition. It may be directed at the only existing problem, or at only one aspect of a larger problem in which a decision is made to defer or forego more comprehensive therapy. D8010 Limited orthodontic Includes panoramic and cephalometric films, diagnostic casts, photos and consultation (records). If the patient agrees to treatment of the treatment, the fee for the records is included in the total treatment fee and is not separately payable. primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition

Delta Dental Utilization Review Guidelines Page 99 1/1/21 D8040 Limited orthodontic treatment of the adult dentition INTERCEPTIVE ORTHODONTIC TREATMENT CDT: Interceptive orthodontics is an extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of dental or recovery of space loss where overall space is inadequate. When initiated during the incipient stages of a developing problem, interceptive orthodontics may reduce the severity of the malformation and mitigate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other conditions may require subsequent comprehensive therapy.

D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition

COMPREHENSIVE ORTHODONTIC TREATMENT CDT: Comprehensive orthodontic care includes a coordinated diagnosis and treatment leading to the improvement of a patient's craniofacial dysfunction and/or dentofacial deformity which may include anatomical, functional and/or aesthetic relationships. Treatment may utilize fixed and/or removable orthodontic appliances and may also include functional and/or orthopedic appliances in growing and non-growing patients. Adjunctive procedures to facilitate care may be required. Comprehensive orthodontics may incorporate treatment phases focusing on specific objectives at various stages of dentofacial development.

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition

MINOR TREATMENT TO CONTROL HARMFUL HABITS D8210 Removable appliance CDT: Removable indicates patient can remove; includes appliances for thumb sucking and tongue thrusting. therapy D8220 Fixed appliance CDT: Fixed indicates patient cannot remove appliance; includes appliances for thumb sucking and tongue thrusting. therapy

OTHER ORTHODONTIC SERVICES

Delta Dental Utilization Review Guidelines Page 100 1/1/21 D8660 Pre-orthodontic CDT: Periodic observation of patient dentition, at intervals established by the dentist, to determine when orthodontic treatment treatment should begin. Diagnostic procedures are documented separately. examination to monitor growth and development a. Benefit for patients with orthodontic coverage. b. Not a benefit for patients with orthodontic history. c. No payment is made and the fee is not billable to the patient by a participating dentist with any other evaluation (D0120-D0180). d. No payment is made for D8660 and the fees are not billable to the patient by a participating dentist when submitted with D8070, D8080, D8090 (comprehensive orthodontic treatment).

D8670 Periodic orthodontic treatment visit D8680 Orthodontic retention a. No payment is made for orthodontic retention and the fee is not billable to the patient within 24 months of placement (removal of by same dentist/dental office. appliances, b. Benefits are DENIED if performed by different dentist/dental office. construction and c. D8680 submitted after 24 months is DENIED. placement of retainer(s)) D8681 Removable No payment is made for removable orthodontic retainer adjustments and the fees are not billable to the patient by a orthodontic retainer participating dentist if performed by the same dentist/dental office providing orthodontic treatment. Benefits are adjustment DENIED if performed by a different dentist/dental office. D8690 Orthodontic CDT: Services provided by dentist other than original treating dentist. A method of payment between the provider and treatment (alternative responsible party for services that reflect an open-ended fee arrangement. billing to a contract DENIED unless covered by group/individual contract. fee) D8695 Removal of fixed Benefits for patient requested removal of fixed orthodontic appliance(s) are DENIED. orthodontic appliances for reasons other than completion of treatment

D8696 Repair of orthodontic CDT: Does not include bracket and standard fixed orthodontic appliances. It does include functional appliances and palatal expanders.

This procedure is generally excluded by group/individual contract. D8697 Repair of orthodontic CDT: Does not include bracket and standard fixed orthodontic appliances. It does include functional appliances and palatal expanders. mandibular

This procedure is generally excluded by group/individual contract. D8698 Re-cement or re-bond a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient anytime following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous maxillary recements and rebonds, individual consideration can always be given. b. In the case where a different dentist/dental office is recementing/rebonding the fixed retainer a separate benefit may be given once in a lifetime and benefits for any additional D8698 are DENIED.

Delta Dental Utilization Review Guidelines Page 101 1/1/21 D8699 Re-cement or re-bond a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient anytime following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous mandibular recements and rebonds, individual consideration can always be given. b. In the case where a different dentist/dental office is recementing/rebonding the fixed retainer a separate benefit may be given once in a lifetime and benefits for any additional D8699 are DENIED.

D8701 Repair of fixed a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient within 24 months retainer, includes following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous repairs, individual consideration can always be given. maxillary b. D8701 submitted after 24 months of placement is DENIED.

D8702 Repair of fixed a. This procedure is included in the orthodontic case fee. A separate fee is not billable to the patient within 24 months retainer, includes following placement of the fixed retainer by the same dentist/dental office. In cases where there are excessive or continuous repairs, individual consideration can always be given. mandibular b. D8702 submitted after 24 months of placement is DENIED.

D8703 Replacement of lost DENIED unless covered by group/individual contract.

maxillary D8704 Replacement of lost DENIED unless covered by group/individual contract.

mandibular D8999 Unspecified CDT: Used for procedure that is not adequately described by a code. Narrative orthodontic Describe procedure. May require IC review by Dental Consultant. procedure, byMEDICALLY report NECESSARY ORTHODONTIC BENEFIT GUIDELINES Definition Orthodontic benefits are limited to those services that are medically necessary as evidenced by a severe and handicapping , for members under the age of 19. Orthodontic procedures are a benefit only when the quantitative, objective method for measuring malocclusion, Handicapping Labio-Lingual Deviation (HLD) Index, meets a minimum score of 28, or meets one or more of the automatic qualifying conditions. Criteria for Coverage Members under age 19 may qualify for orthodontic care. require prior authorization. No benefit payment will be made if the treating dentist does not obtain a prior authorization before rendering services.

documentation OR meets one or more of the following automatic qualifying conditions ·· Cleft ·· Deep Impinging ·· Anterior Impactions ·· Severe Traumatic Deviations ·· greater than 9 mm ·· Severe Maxillary Anterior Crowding, greater than 8 mm

Procedure Codes Interceptive Orthodontic Treatment Benefit is limited to one of the following procedures per patient per lifetime Procedure D8050 Interceptive orthodontic treatment of the primary dentition Procedure D8060 Interceptive orthodontic treatment of the transitional dentition

Delta Dental Utilization Review Guidelines Page 102 1/1/21 Comprehensive Orthodontic Treatment Benefit is limited to once per patient per lifetime Procedure D8080 Comprehensive orthodontic treatment of the adolescent dentition Multi-phase orthodontic treatment requires prior authorization at each phase and must meet the criteria for coverage for Medically Necessary Orthodontics (MNO). Each prior authorization will require a new, updated HLD form detailing the

The fee for orthodontic treatment includes all diagnostic procedures (exam, photographs, x-rays), appliances, post- treatment stabilization, etc. Documentation requesting prior authorization with the appropriate CDT procedure code, total case fee and months of Requirements treatment

the images were taken ~Lateral views must expose the buccal dentition; soft tissue retractors must be used ~Occlusal views must be taken with a mirror so as to include as many teeth as possible being careful to retract the soft tissue of the lower

~ All documents must be received to determine if the case qualifies for medically necessary benefits. ~ Radiographs and photographs must be of diagnostic quality. ~ Minimum HLD score to be considered for approval is 28.

by the submitted documentation.

Prior Authorization No benefit payment will be made if the dentist does not obtain a prior authorization before rendering services.

Delta Dental Utilization Review Guidelines Page 103 1/1/21 Professional Review In order to be considered for benefits, the claim for prior authorization of orthodontic services must include all of the

included, the claim will be processed indicating no benefit determination can be made until all required information is received.

The first level of review involves an initial determination by a trained dental case management analyst to determine if the

All claims not approved for payment are forwarded to a dental consultant (licensed dentist) for further review and

determination notices state the reason(s) for the determination.

If the prior authorization is denied because it does not meet the criteria for medical necessity as determined by our dental consultant, we offer two levels of internal appeal. An appeal must be requested in writing within 180 calendar days from the date of receipt of the initial denial notice. An orthodontic dental consultant not involved in the previous denial will review the appeal and render a decision based on the new information provided. We will send the appeal decision in writing to the patient and the dentist. If a second appeal is requested, it must be done in writing within 180 calendar days from the date of the first appeal denial notice. A different orthodontic dental consultant will review the second appeal. We will send the appeal decision in writing to the patient and the dentist.

If the two levels of internal appeal have been exhausted, an external appeal can be initiated in writing. The external

will be reprocessed.

If the case does not qualify for Medically Necessary Orthodontics and does not meet a minimum HLD score of 28, the patient is responsible for the entire case fee, including the workup (i.e. x-rays, diagnostic casts, photographs, etc.) Billing for Approved The start/billing date of orthodontic services is defined as the date the bands, brackets or appliances are placed in the Services The member must be eligible for services on the date of banding. Once the member turns 19, he/she is no longer eligible for the remaining months of treatment.

Upon banding, payment for Medically Necessary Orthodontic cases will be evenly spread over the expected length of the treatment as long as the child remains eligible for coverage. Benefits will be paid automatically, in quarterly installments, as long as the member remains eligible for coverage, and is in active treatment.

Delta Dental Utilization Review Guidelines Page 104 1/1/21 Continuation of Care The following information is required for orthodontic cases already in progress. (i.e. member had coverage with a different carrier, or had no coverage at all and now becomes eligible with Delta Dental.)

carrier, include the original HLD form)

the images were taken ~Lateral views must expose the buccal dentition; soft tissue retractors must be used ~Occlusal views must be taken with a mirror so as to include as many teeth as possible being careful to retract the soft tissue of the lower lip

~ All documents must be received to determine if the case qualifies for medically necessary benefits. ~ Radiographs and photographs must be of diagnostic quality. ~ Minimum HLD score to be considered for approval is 28.

by the submitted documentation.

A benefit approval from a previous carrier does not apply to Delta Dental. In order to qualify for medically necessary

If the MNO case has been approved by Delta Dental and mid treatment the patient changes dentists, the approval will be honored. D9000-D9999 ADJUNCTIVE GENERAL SERVICES **If the procedure reported was the result of an accident, it should be submitted to the patient's medical and/or liability insurer first.**

disinfection as a stand alone procedure is denied as investigational.

billed as a stand alone procedure, low level laser therapy is denied as investigational.

conventional methods are adequate. UNCLASSIFIED TREATMENT D9110 Palliative CDT: This is typically reported on a "per visit" basis for emergency treatment of dental pain. (emergency) Benefits are available only if no other service is rendered during the visit except any type of an exam, pulp test and x- treatment of dental rays necessary to diagnose the emergency condition. A separate fee for palliative treatment cannot be charged to the pain - minor patient. Palliative treatment in conjunction with root canal therapy by the same dentist/dental office on the same date of procedure service is included in the fee for the root canal and is not separately billable. Palliative treatment is limited to two (2) occurrences per calendar year. Palliative treatment may include: -Limited occlusal adjustment -Desensitizing medicaments -Scaling and curettage of a periodontal abscess in a tooth segment -Pulpotomy performed on a patient over the age of 14 ­operative care and are not separately billable.)

Delta Dental Utilization Review Guidelines Page 105 1/1/21 Dental Consultant Criteria/Notes: Palliative treatment is defined as emergency treatment to alleviate pain only. Whenever the procedure performed can be identified by an existing code, the code describing the service performed should be submitted.

Rationale: 1. Palliative treatment is defined as emergency treatment to alleviate pain only. 2. Emergency palliative treatment is payable on a per visit basis, once on the same date. All procedures necessary for relief of pain are included in the fee for the D9110. Examination is not considered a relief of pain.

Palliative treatment may be a benefit when definitive care is performed, at the same appointment, if the treatment sites are different. (D1999) Rationale: 1. Diagnostic aids are considered a necessary part of treatment in determining and in giving relief of pain. 2. The procedure is considered a relief of pain and for patient stabilization when performed on a different date of service.

D9120 Fixed partial denture CDT: Separation of one or more connections between abutments and/or pontics when some portion of a fixed Tooth number, pre- sectioning prosthesis is to remain intact and serviceable following sectioning and extraction or other treatment. Includes all operative x-ray, narrative recontouring and polishing of retained portions. or clinical treatment notes

This procedure is only a benefit if a portion of a fixed prosthesis is to remain intact and serviceable following sectioning and extraction or other treatment. If the procedure is part of the process of removing and/or replacing a fixed prosthesis, it is considered part of the comprehensive procedure and the fee is not billable to the patient by a participating dentist /DENIED - non-participating dentist. D9130 Temporomandibular CDT: Therapy including but not limited to massage, diathermy, ultrasound, or cold application to provide relief from muscle spasms, inflammation or pain, intending to improve freedom of motion and joint function. This should be non-invasive physical reported on a per session basis. therapies a. Non-invasive TMD physical therapies are DENIED unless covered by group/individual contract. b. If covered by group/individual contract, benefit once every 12 months.

ANESTHESIA Local anesthesia is used to allow the patient more comfort in performing operative and surgical procedures. It has become a basic part of restorative and surgical procedures and should be an integral part of the procedure and not a separate benefit. D9210 Local anesthesia not Local anesthesia when rendered in conjunction with codes D1110, D4346, D4355, D4910 is denied. No payment is made in conjunction with for anesthesia performed with all other codes and the fee is not billable to the patient by a participating dentist. operative or surgical procedures

D9211 Regional block No payment is made and the fee is not billable to the patient by a participating dentist with all procedures. anesthesia D9212 Trigeminal division No payment is made and the fee is not billable to the patient by a participating dentist with all procedures. block anesthesia D9215 Local anesthesia in Local anesthesia when rendered in conjunction with codes D1110, D4346, D4355, D4910 is denied. No payment is made conjunction with for anesthesia performed with all other codes and the fee is not billable to the patient by a participating dentist/DENIED - operative or surgical non-participating dentist. procedures

Delta Dental Utilization Review Guidelines Page 106 1/1/21 D9219 Evaluation for No payment is made for evaluation for moderate sedation, deep sedation or general anesthesia and the fees are not moderate sedation, billable to the patient by a participating dentist with moderate, deep sedation or general anesthesia. deep sedation or general anesthesia D9222 Deep CDT: Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia sedation/general and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are considered completed when the patient may be safely left under the observation of trained personnel and the doctor minutes may safely leave the room to attend to other patients or duties.

central nervous system and not dependent upon the route of administration.

D9223 Deep a. Deep sedation/general anesthesia is a benefit only when administered with appropriate monitoring by a properly sedation/general licensed provider who is acting in compliance with applicable State rules and regulations. b. The benefit for deep sedation/general anesthesia is DENIED when billed by anyone other than an appropriately subsequent 15 minute licensed and qualified provider. increment [The difference between general anesthesia and intravenous sedation is that the patient cannot support his/her own airway while under general anesthesia.] Drugs typically used: Fentanyl, Versed or Valium, Sodium Brevital General anesthesia is allowed with these services: (when the procedure is a covered benefit): Apicoectomy (D3410- D3426); Retrograde filling (D3430); Root amputation (D3450); Hemisection (D3920); Surgical extractions (D7210- D7241); Root recovery (D7250); Coronectomy (D7251); Other oral surgery procedures (D7260-D7291); Alveoloplasty (D7310-D7321); Vestibuloplasty (D7340-D7350); Removal of tumors, cysts and neoplasms (D7410-D7461); Excision of bone tissue (D7471-D7490); Surgical Incision (D7510-D7560); Treatment of fractures-simple (D7610-D7680); Treatment of fractures-compound (D7710-D7780); Reduction of dislocation of temporomandibular joint (D7810-D7877); Repair of traumatic wounds (D7910); Excision of hyperplastic tissue (D7970).

Anesthesia will be allowed for certain covered surgical procedures and will be paid per tooth/site. Durations exceeding the following on the same date of service will be denied.

No payment is made for durations exceeding 60 minutes and a participating dentist cannot bill the patient. Providing more than 60 minutes of deep sedation or general anesthesia for routine dental procedures is unusual and additional submissions should only be considered on a by report basis.

D9230 Inhalation of nitrous Analgesia is not a covered benefit. The fee is denied unless the group individual contract specifies that is a benefit. If oxide/analgesia, covered, no payment is made for multiple submissions on the same date of service and the fees are not billable to the anxiolysis patient by a participating dentist. No payment is made in conjunction with I V sedation and general anesthesia and the fee is not billable to the patient by a participating dentist. Limited to invasive procedures.

[The difference between general anesthesia and intravenous sedation is that the patient cannot support his/her own airway while under general anesthesia.]

Delta Dental Utilization Review Guidelines Page 107 1/1/21 D9239 Intravenous moderate CDT: Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia (conscious) and non-invasive monitoring protocol and remains in continuous attendance of the patient. Anesthesia services are sedation/analgesia- considered completed when the patient may be safely left under the observation of trained personnel and the doctor first 15 minutes may safely leave the room to attend to other patients or duties.

central nervous system and not dependent upon the route of administration.

D9243 Intravenous moderate a. Intravenous moderate (conscious) sedation/analgesia is a benefit only when administered in a dental office with (conscious) appropriate monitoring by an appropriately licensed and qualified dentist who is acting in compliance with applicable rules and regulations. Otherwise, the benefit for intravenous moderate (conscious) sedation/analgesia is DENIED. each subsequent 15 b. The benefit for intravenous moderate (conscious) sedation/analgesia is DENIED when billed by anyone other than an minute increment appropriately licensed and qualified dentist.

IV Sedation is allowed with these services: (when the procedure is a covered benefit): Apicoectomy (D3410-D3426); Retrograde filling (D3430); Root amputation (D3450); Hemisection (D3920); Surgical extractions (D7210-D7241); Root recovery (D7250); Coronectomy (D7251); Other oral surgery procedures (D7260-D7291); Alveoloplasty (D7310-D7321); Vestibuloplasty (D7340-D7350); Removal of tumors, cysts and neoplasms (D7410-D7461); Excision of bone tissue (D7471- D7490); Surgical Incision (D7510-D7560); Treatment of fractures-simple (D7610-D7680); Treatment of fractures- compound (D7710-D7780); Reduction of dislocation of temporomandibular joint (D7810-D7877); Repair of traumatic wounds (D7910); Excision of hyperplastic tissue (D7970).

Anesthesia will be allowed for certain covered surgical procedures and will be paid per tooth/site. Durations exceeding the following on the same date of service will be denied.

No payment is made for durations exceeding 60 minutes and a participating dentist cannot bill the patient. Providing more than 60 minutes of intravenous moderate (conscious) sedation for routine dental procedures is unusual and additional submissions should only be considered on a by report basis. D9248 Non-intravenous CDT: This includes non-IV minimal and moderate sedation. conscious sedation A medically controlled state of depressed consciousness while maintaining the patient's airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes non-intravenous administration of sedative and/or agents(s) and appropriate monitoring. The level of anesthesia is determined by the anesthesia provider's documentation of the anesthetic's effects upon the central nervous system and not dependent upon the route of administration. DENIED unless covered by group/individual contract. PROFESSIONAL CONSULTATION D9310 Consultation - CDT: A patient encounter with a practitioner whose opinion or advice regarding evaluation and/or management of a diagnostic service specific problem; may be requested by another practitioner or appropriate source. The consultation includes an oral provided by dentist or evaluation. The consulted practitioner may initiate diagnostic and/or therapeutic services. physician other than requesting dentist or Consultation (D9310) should be included in the evaluation (D0120,D0140, D0145, D0150, D0160, D0170, D0171 and physician D0180) fee. The fee for the consultation (D9310) is not billable to the patient by a participating dentist when billed in conjunction with an evaluation (D0120, D0140, D0145, D0150, D0160, D0170, D0171 and D0180) by the same dentist/dental office.

Delta Dental Utilization Review Guidelines Page 108 1/1/21 D9311 Consultation with a CDT: Treating dentist consults with a medical health care professional concerning medical issues that may affect medical health care professional The fees for the consultation with a health care professional concerning medical issues is not billable to the patient by a participating dentist. Rationale: Consultation with health care professional concerning medical issues is inclusive of the comprehensive medical management of the patient. PROFESSIONAL VISITS D9410 House/extended care CDT: Includes visits to nursing homes, long-term care facilities, hospice sites, institutions, etc. Report in addition to facility call reporting appropriate code numbers for actual services performed. DENIED unless covered by group/individual contract. D9420 Hospital or CDT: Care provided outside the dentist's office to a patient who is in hospital or ambulatory surgical center. Services ambulatory surgical delivered to the patient on the date of service are documented separately using the applicable procedure codes. center call DENIED unless covered by group/individual contract. D9430 Office visit for DENIED unless covered by group/individual contract. observation (during If covered: regularly scheduled 1-No payment is made and the fee is not billable to the patient by a participating dentist for multiple submissions on the same date of service. services performed 2-No payment is made and the fee is not billable to the patient by a participating dentist in conjunction with IV sedation and general anesthesia. Limited to invasive procedures.

D9440 Office visit - after DENIED unless covered by group/individual contract. regularly scheduled hours D9450 Case presentation, CDT: Established patient. Not performed on same day as evaluation. detailed and extensive DENIED unless covered by group/individual contract. treatment planning

DRUGS D9610 Therapeutic CDT: Includes single administration of , steroids, anti-inflammatory drugs, or other therapeutic medications. parenteral drug, single This code should not be used to report administration of sedative, anesthetic or reversal agents. administration DENIED unless covered by group/individual contract. For those groups with coverage, this procedure is limited to once per calendar year. D9612 Therapeutic CDT: Includes multiple administration of antibiotics, steroids, anti-inflammatory drugs or other therapeutic medications. parenteral drug, two This code should not be used to report administration of sedatives, anesthetic or reversal agents. or more This code should be reported when two or more different medications are necessary and should not be reported in administrations, addition to code D9610 on the same date. different medications DENIED unless covered by group/individual contract.

D9613 Infiltration of CDT: Infiltration of a sustained release pharmacologic agent for long acting surgical site pain control. Not for local sustained release anesthesia purposes. Benefits for infiltration of sustained release therapeutic drug are DENIED as a specialized procedure unless covered by single or multiple sites group/individual contract. When covered; a. Benefit D9613 once per date of service. b. D9613 is only a benefit when submitted with surgical extractions (D7220-D7241).

D9630 Drugs or CDT: Includes, but is not limited to oral antibiotics, oral , and topical fluoride dispensed in the office for home medicaments use; does not include writing prescriptions. dispensed in the Delta Dentaloffice for Utilization home use Review Guidelines Page 109 1/1/21 Drugs or medicaments dispensed in the DENIED unless covered by group/individual contract. office for home use

MISCELLANEOUS SERVICES D9910 Application of CDT: desensitizing fluoride. This code is not to be used for bases, liners or adhesives used under restorations. medicament DENIED unless covered by group/individual contract. For those groups that do provide coverage, one visit per calendar year and must have history of any of the following: D4240, D4241, D4260, D4261, D4341, D4342.

D9911 Application of CDT: desensitizing resin for liners or adhesives used under restorations. cervical and/or root DENIED unless covered by group/individual contract. surface

D9920 Behavior CDT: May be reported in addition to treatment provided. Should be reported in 15- minute increments. management, by DENIED unless covered by group/individual contract. report D9930 Treatment of CDT: For example, treatment of a dry socket following extraction or removal of bone sequestrum. complications (post- surgical) - unusual a. The fee for dry socket is not billable to the patient by a participating dentist within 30 days following the extraction circumstances, by and included in the fee for the extraction by the same dentist/dental office. report b. Benefit treatment of routine complications if done by a different dentist/dental office.

D9932 Cleaning and CDT: This procedure does not include any adjustments. inspection of No payment is made for cleaning and inspection of a removable complete denture and the fees are not billable to the removable complete patient by a participating dentist when done with a reline or rebase procedure. In all other instances, benefits for denture, maxillary cleaning and inspection of a removable complete denture are DENIED unless covered by group/individual contract. When covered, count towards prophylaxis frequency.

D9933 Cleaning and CDT: This procedure does not include any adjustments. inspection of No payment is made for cleaning and inspection of a removable complete denture and the fees are not billable to the removable complete patient by a participating dentist when done with a reline or rebase procedure. In all other instances, benefits for denture, mandibular cleaning and inspection of a removable complete denture are DENIED unless covered by group/individual contract. When covered, count towards prophylaxis frequency.

D9934 Cleaning and CDT: This procedure does not include any adjustments. inspection of No payment is made for cleaning and inspection of a removable partial denture and the fees are not billable to the removable partial patient by a participating dentist when done with a reline or rebase procedure. In all other instances, benefits for denture, maxillary cleaning and inspection of a removable partial denture are DENIED.

D9935 Cleaning and CDT: This procedure does not include any adjustments. inspection of No payment is made for cleaning and inspection of a removable partial denture and the fees are not billable to the removable partial patient by a participating dentist when done with a reline or rebase procedure. In all other instances, benefits for denture, mandibular cleaning and inspection of a removable partial denture are DENIED.

D9944 CDT: Removable dental appliance designed to minimize the effects of or other occlusal factors. Not to be appliance, full arch reported for any type of sleep apnea, snoring or TMD appliances.

Delta Dental Utilization Review Guidelines Page 110 1/1/21 D9945 CDT: Removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Not to be appliance, full arch reported for any type of sleep apnea, snoring or TMD appliances.

D9946 CDT: Removable dental appliance designed to minimize the effects of bruxism or other occlusal factors. Provides only appliance, partial arch partial occlusal coverage such as anterior deprogrammer. Not to be reported for any type of sleep apnea, snoring or TMD appliances. a. Benefits for occlusal guard are DENIED unless covered by group/individual contract. b. If covered by group contract, allow once every three years. Rationale: Benefits related to attrition, erosion, abrasion, abfraction, corrosion are not a covered benefit. ~ Occlusal guards submitted in conjunction with TMJ therapy are not covered. Deny. (If the subscriber's contract has a TMJ rider, this procedure should be processed as a D7880). D9941 Fabrication of athletic DENIED unless covered by group/individual contract. mouthguard

D9942 Repair and/or reline Covered once in a 12 month period for those subscribers who have coverage for an occlusal guard or who have a TMJ of occlusal guard rider. This procedure is part of the initial procedure if performed within 6 months of delivery and the fee is not billable to the patient by a participating dentist. D9943 Occlusal guard Benefits for occlusal guard adjustments are DENIED unless covered by group/individual contract. adjustment a. When covered by contract no payment is made for all adjustments within 6 months and the fees are not billable to the patient by a participating dentist. b. Allow one per year following six months from initial placement. D9950 Occlusion analysis - CDT: Includes, but is not limited to, facebow, interocclusal records tracings and diagnostic wax-up; for diagnostic casts, mounted case see D0470. Not a covered benefit unless the subscriber's contract has a TMJ rider. D9951 Occlusal adjustment - CDT: May also be known as equilibration; reshaping the occlusal surfaces of teeth to create harmonious contact limited relationships between the maxillary and mandibular teeth. Presently includes discing/odontoplasty/enamoplasty. Typically reported on a "per visit" basis. This should not be reported when the procedure only involves bite adjustment in the routine post-delivery care for a direct/indirect restoration or fixed/removable prosthodontics.

DENIED unless covered by group/individual contract. For those subscribers with coverage (i.e..: TMJ Rider), this procedure is limited to once per calendar year. D9952 Occlusal adjustment - CDT: Occlusal adjustment may require several appointments of varying length, and sedation may be necessary to attain complete adequate relaxation of the musculature. Study casts mounted on an articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal adjustment enhances the healing potential of tissues affected by the lesions of .

DENIED unless covered by group/individual contract. For those subscribers with coverage (i.e..: TMJ Rider), this procedure is limited to once per calendar year. D9961 Duplicate/copy Benefits for patient record duplication are DENIED. patient's records Rationale: Administrative services are not covered. D9970 Enamel microabrasion CDT: The removal of discolored surface enamel defects resulting from altered mineralization or decalcification of the superficial enamel layer. Submit per treatment visit. DENIED unless covered by group/individual contract. D9971 Odontoplasty - per CDT: Removal/reshaping of enamel surfaces or projections. tooth DENIED unless covered by group/individual contract.

Delta Dental Utilization Review Guidelines Page 111 1/1/21 D9972 External bleaching - DENIED unless covered by group/individual contract. per arch- performed in office D9973 External bleaching - DENIED unless covered by group/individual contract. per tooth D9974 Internal bleaching - DENIED unless covered by group/individual contract. per tooth If covered, allow once per 12 months per tooth. Benefits are denied within 12 months of D9972 external bleaching - per arch. D9975 External bleaching for DENIED unless covered by group/individual contract. home application, per arch; includes materials and fabrication of custom trays

D9985 Sales tax Sales/service charges are not a benefit of dental plans and are DENIED. D9986 Missed appointment Not a procedure therefore the benefit is denied. D9987 Cancelled Not a procedure therefore the benefit is denied. appointment D9990 Certified translation or Unless covered by group/individual contract, no payment is made for translation services and the fees are not billable to sign-language the patient by a participating dentist as they are considered inclusive in overall patient management.

D9991 Dental case CDT: Individualized efforts to assist a patient to maintain scheduled appointments by solving transportation challenges or other barriers. addressing appointment compliance barriers Actions taken to schedule and assure compliance with patient appointments are inclusive with office operations and is therefore not billable to the patient by a participating dentist. Rationale: Arrangement for transportation services is included in overall patient management. D9992 Dental case CDT: provider types, areas of treatment, health care settings, health care organizations and payment systems. This is coordination the additional time and resources expended to provide experience or expertise beyond that possessed by the patient.

The fees for care coordination are considered inclusive in overall patient management and are not billable to the patient by a participating dentist. Rationale: Included in evaluation and overall patient management. D9993 Dental case CDT: Patient-centered, personalized counseling using methods such as Motivational Interviewing (MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a separate service from traditional nutritional or motivational tobacco counseling. interviewing

Personalized counseling is not a covered benefit and is DENIED. No payment is made for motivational interviewing and the fees are not billable to the patient by a participating dentist when submitted on same date of service as D1310, D1320, D1330.

Delta Dental Utilization Review Guidelines Page 112 1/1/21 D9994 Dental case CDT: Individual, customized communication of information to assist the patient in making appropriate health decisions designed to improve oral health literacy, explained in a manner acknowledging economic circumstances and different education to improve cultural beliefs, values, attitudes, traditions and language preferences, and adopting information and services to these oral health literacy differences, which requires the expenditure of time and resources beyond that of an oral evaluation or case presentation.

Patient education is not a benefit and is DENIED. No payment is made for patient education to improve oral health literacy and the fees are not billable to the patient by a participating dentist when submitted on same date of service as D1310, D1320, D1330. D9997 Dental case CDT: Special treatment considerations for patients/individuals with physical, medical, developmental or cognitive management - conditions resulting in substantial functional limitations, which require that modifications be made to delivery of patients with special treatment to provide comprehensive oral health care services. health care needs

The fees for patients with special health care needs are considered administrative and used to identify services provided to a particular type of patient and are not billable to the patient by a participating dentist.

D9995 CDT: Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service. synchronous; real- time encounter The fees for teledentistry-synchronous are considered inclusive in overall patient management and are not billable to the patient by a participating dentist. Rationale: Teledentistry codes are considered administrative.

D9996 CDT: Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service. asynchronous; information stored and forwarded to dentist for subsequent review

The fees for teledentistry-asynchronous are considered inclusive in overall patient management and are not billable to the patient by a participating dentist. Rationale: Teledentistry codes are considered administrative.

Delta Dental Utilization Review Guidelines Page 113 1/1/21 The following services are covered with teledentistry:

Teledentistry codes D9995 or D9996 must be submitted with procedure codes D0120, D0140, D0170 and D0171 when conducted as a teledentistry visit to ensure timely payment. Code D0150 (Comprehensive oral evaluation - new or established patient) when submitted as a teledentistry visit will be changed to an alternate benefit of D0140 and will be paid subject to normal limitations/frequencies. Benefit plan deductibles, copayments, and time and frequency limitations will apply equally to teledentistry and in- person exams as of August 3, 2020. Time and frequency limitations also apply to exams performed prior to March 18, 2020. (Note: Members who had teledentistry exams between March 18 and August 2, 2020 are not subject to time and frequency limitations, in accordance with our Emergency Teledentistry Policy). To qualify as a teledentistry exam, the exam must be conducted by telephone or other telecommunications system with the dentist using videos, photographs, x-rays or other diagnostic tools for diagnosis and treatment recommendations. Teledentistry is not a service, but a means by which to deliver a service when the patient is in one location and the dentist is in another. The means by which teledentistry services are delivered must be in accordance with applicable

information. The treatment of patients who receive an exam by teledentistry must be properly documented in the

service will be treated as an exam and charged as such should be communicated to the patient and documented.

Documentation Requirements: D0120 Periodic oral evaluation: The following documentation is required: o Intra-oral photos of any suspicious soft/hard tissues and problem areas or teeth o Review of new or existing x-rays o Clinical treatment notes should support findings D0140 Limited oral evaluation - problem focused: Clinical treatment notes must detail the conversation with the patient and include, but are not limited to:

o Specific area/or tooth or problem initiating the phone call o Symptoms: pain, swelling, cold/hot/biting sensitivity o Problem timeline: when started o Symptom progression, i.e.: Same, worse, better o Treatment rendered: prescriptions/referrals/verbal patient instructions The exam will only qualify as a teledentistry exam if the following is documented in the clinical treatment notes: o A review of existing treatment notes, x-rays and Intra-oral photos and/or o A review of the images the patient provided via cell phone, photos, etc. These should be uploaded into the patient record.

Same documentation as D0140.

Same documentation as D0140.

D9999 Unspecified CDT: Used for procedure that is not adequately described by a code. Narrative adjunctive procedure, Describe procedure. May require IC review by Dental Consultant. by report EVIDENCE-BASED DENTISTRY (EBD)

Delta Dental Utilization Review Guidelines Page 114 1/1/21 The following is a list of procedures that are considered EBD. A subscriber may elect to add one or more of these benefits. 1 - Single Tooth Implants: Codes D6010, D6013, D6056 and D6057 Single tooth implants are covered at 50% once per lifetime per tooth, subject to the calendar year maximum. This benefit includes the surgical placement of the implant body and the prefab or custom abutment. The crown over the implant is benefited once every 84 months. Note: A subscriber cannot have coverage for a Single Tooth Implant and a separate Implant Rider. 2 - Sealants: Code D1351 Sealants are covered 100% for dependent children under age 16 for all unrestored permanent molars and premolars once every 24 months. Teeth included: Molars - 2, 3, 14, 15, 18, 19, 30 and 31. Premolars - 4, 5, 12, 13, 20, 21, 28 and 29. 3 - Oral Exams: Code D0120, D0140, D0150, D0160, D0170 and D0180 One oral exam is covered every 6 months regardless of specialty. 4 - Topical Fluoride Varnish: Code D1206 Topical Fluoride Varnish is covered 100% once per 12 months for all members over the age of 16 following gingival flap and/or osseous surgery (D4240, D4241, D4260 and D4261). 5 - Cleanings: Codes D1110, D4346, D4910 At Risk Benefit Members are eligible for 4 cleanings (D1110, D4346) per year (administered as 1 every 3 months), if the member is in the "at risk" population. A diabetic/immuno-suppressed member with no evidence of previous periodontal disease will receive coverage for a 3rd and 4th cleaning (D1110, D4346) per year. A pregnant woman with no evidence of previous periodontal disease will receive coverage for a 3rd cleaning (D1110, D4346) per year (since administered as 1 cleaning per 3 months, pregnant women are limited to 3 cleanings during the 9-month pregnancy). All other patients who are not deemed "at risk" are eligible for the current standard benefit of 1 cleaning every 6 months.

Conditions that qualify: Diabetes, Organ Transplants, Pregnancy, HIV/Aids, chemotherapy for cancer Periodontal Benefit Members who have undergone osseous surgery (D4260, D4261), scaling and root planing (D4341, D4342) or gingival flap surgery (D4240, D4241) will now be eligible for 4 periodontal maintenance (D4910) procedures per year (administered as 1 every 3 months). 6 - X-Rays: Codes D0330 and D0210 Panorex and Full Mouth X-Rays will be subject to a 60-month time limitation (5 years). Single tooth x-rays will remain covered as needed. Bitewing x-rays will be covered once every 12 months (a change from the current policy of once per calendar year). 7 - Crowns: Codes D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2950, D2952 and D2954 Single tooth crowns, buildups and post and cores will be subject to an 84 month time limitation (7 years) for replacement. The existing 60-month time limitation will remain unchanged for bridges and dentures. Replacement crowns are subject to a 7-year limitation. 8 - Periodontal Benefits: Codes D4210, D4211, D4240, D4241, D4245, D4249, D4260, D4261, D4263, D4264, D4266, D4267, D4268, D4270, D4273, D4274, D4275, D4276, D4277, D4278, D4341, D4342 and D4910

The current standard benefit is increased from 50% to 80% for covered periodontal procedures (non-covered periodontal codes: D4230, D4231, D4265, D4320, D4321). 9 - Bone Replacement Graft and Guided Tissue Regeneration: Codes D4263, D4264, D4266 and D4267

Coverage for bone grafts at an extraction site along with guided tissue regeneration in preparation for an implant as well as for natural teeth.

Delta Dental Utilization Review Guidelines Page 115 1/1/21 10 - Maximum Carryover Provision This provision will permit accounts to allow members to carry over a set dollar amount that can be used in a future year. The following conditions apply: ~ A subscriber MUST have coverage for both crowns and prosthodontics. ~ Member (subscriber and enrolled dependents are eligible) must be enrolled in a plan for the entire previous calendar/policy year. ~ Member must have had a preventive service (D1120 - child cleaning, D1110 - adult cleaning, D4346 - scaling in presence of generalized moderate or severe gingival inflammation, D4910 - periodontal maintenance) within the previous calendar/policy year to qualify for a carry over. ~ Total claim activity cannot exceed the paid claims threshold (group determined) during the calendar year. ~ Determination of carryover amounts will be calculated in March of the following year. This amount will be made available for members at that time. ~ The Maximum Carryover Provision only applies to the benefits paid through the calendar year maximum. ~ The yearly maximum must be $1,000.00 or more ~ Claims are processed using the dollars available in the yearly maximum first. ~ There are additional benefit dollars available (stipend) if the member has had all their work performed by participating dentists.

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