x = a radiograph image must be included r = a report must ... · - Dentures and partials date of...
Transcript of x = a radiograph image must be included r = a report must ... · - Dentures and partials date of...
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x = a radiograph image must be included
r = a report must be included
fx = a pre and post operative
radiograph image must be included
* = apply only under orthodontic
benefits
GP = GENERAL POLICES
D0100 - D0999 I. DIAGNOSTIC
NOTE: Completion date or date procedure must be billed to Delta
Dental of PR, Inc. is:
- Dentures and partials date of insertion or delivery.
- Crowns and fixed bridges day of cementation.
- Endodontic and periodontal treatment the completion date of
the procedure.
Clinical oral examinations
GP - Infection control and tray or tray preparation are included in
the fee for the dental services provided.
GP - Appliances, procedures or restorations to correct congenital
or developmental malformation are not covered.
GP - The time limitation for examinations is established by the
contract. Any combination of D0150, D0120 or D0140 count
toward the contract limitations.
GP - Oral examinations D0150 and D0120 include examination of
all hard and soft tissue of the cavity including periodontal
charging and oral cancer examination.
GP - The fee for consultation, diagnosis and treatment planning is
part of the fee for the examination and/or diagnostic procedure (s).
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D0120 periodic oral evaluation - established patient
Periodic oral evaluations are paid as periodic oral examinations,
once every 6 month.
D0140 limited oral evaluation - problem focused
Limited oral evaluation - problem focused is paid as an emergency
examination and is paid once in a 12 month period.
D0150 comprehensive oral evaluation - new or established patient
Comprehensive oral evaluation are paid as initial oral examination
for the first encounter with the dentist/ dental office and
subsequent submissions are paid as periodic oral examinations
00120, once every 6 month.
D0160 detailed and extensive oral evaluation - problem focused, by report
For special consultation only and limited to one in a 12 month
period. Paid only to specialist, (Endodontics, Periodontics, Oral
Surgeons and Orthodontics).
Radiographs
GP – Diagnostic services such as radiographs must be necessary
and done in connection with covered services. Connection and/ or
need not evident from information submitted.
GP – Non- diagnostic radiographs are not payable. Determination
by dentist consultant review.
GP – The time limitation for radiographs is established by the
contract but usually allows 1 set of bitewing x-rays in a 6 month
period or a full mouth series or panorex in a 3 year period.
Additional x-rays are optional services and may be charge to the
patient.
GP - individually listed radiographs are considered a complete
series if the fee equals or exceeds the fee for a complete series.
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D0210 intraoral - complete series of radiographic images
An intraoral complete series consist of all necessary periapicals
and bitewings. Time limitation of 36 months.
D0220 intraoral - periapical first radiographic image
D0230 intraoral - periapical each additional radiographic image
Routine working and final treatment radiographs are part of the
complete treatment procedure and not a separate benefit.
The time limitation for radiographs is established by contract, but
preferably should be limited to no more than 6 as a combination of
periapicals and bitewings in a one year period.
D0240 intraoral - occlusal radiographic image
D0250 extraoral - first radiographic image
D0260 extraoral - each additional radiographic image
D0270 bitewing - single radiographic image
D0272 bitewings - two radiographic images
bitewings are limited to once in a 6 month period.
D0274 bitewings - four radiographic images
Limited to once in a 12 month period
D0290 posterior-anterior or lateral skull and facial bone survey
radiographic image
Not covered
Only with ortho covered benefit
D0310 sialography
Not covered
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D0320 temporomandibular joint arthrogram, including injection
Not covered
D0321 other temporomandibular joint radiographic images, by report
Not covered
D0322 tomographic survey
Not covered
D0330 panoramic radiographic image
Time limitations of 36 months.
* D0340 cephalometric radiographic image
Cephalometric film is a covered benefit once in a lifetime only for
orthodontic treatment in connection with orthodontic benefits.
* D0350 2D oral/facial photographic image obtained
intra-orally or extra-orally
Diagnostic photographs are only covered in connection with
orthodontic benefit, once in a lifetime.
Test and laboratory examinations
D0415 collection of microorganisms for culture and sensitivity
Collection of microorganisms for determination of pathologic
agents are not a covered.
D0425 caries susceptibility test.
Not covered
D0460 pulp vitality test
D0470 diagnostic casts
Diagnostic casts are payable only once per case in connection with
orthodontic benefit. Casts taken during or after treatment are
included in the fee for orthodontic services. Once in a lifetime.
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D0502 other oral pathology procedures, by report.
Not covered
r D0999 unspecified diagnostic procedure, by report
D1000 - D1999 II. PREVENTIVE
Dental Prophylaxis
GP - A prophylaxis done in the same date as a periodontal
prophylaxis, curettage, scaling or root planning is considered to be
part of and included in those procedures.
GP - The time limitation for prophylaxis is established by contract.
Additional prophylaxis are optional and may be charged to the
patient. 04910 is counted toward the contract limitation for
prophylaxis.
GP - A difficult prophylaxis can be given special consideration
and an additional fee can be paid. A difficult prophylaxis will be
limited to once in a lifetime.
D1110 prophylaxis - adult
A person age 12 and older is provided a prophylaxis adult.
D1120 prophylaxis - child
A person under the age 12 is provided a prophylaxis child
D1206 topical application of fluoride varnish
D1208 topical application of fluoride – excluding varnish
Prophylaxis not included - child under 19.
Other preventive services
GP - Plaque control, tobacco counseling for the control of dental
disease, oral hygiene and dietary instructions are optional benefits.
If performed, these services should be done with the agreement of
the patient to assume the cost.
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D1310 nutritional counseling for control of dental disease
Not covered
D1320 tobacco counseling for the control and prevention of oral disease
Not covered
D1330 oral hygiene instructions
Not covered
D1351 sealant - per tooth
Sealants are payable once per tooth on the occlusal surface of
permanent molars and bicuspids to patients under 14. The teeth
must be free from caries and restorations on the occlusal surface.
The fee for sealants completed on the same date of service and on
the same tooth as a restoration is included in the fee for the
restoration.
No other restoration will be covered within 24 months after a
sealants is placed.
Sealant-per tooth is limited to one benefit per tooth per lifetime.
Space maintenance (passive appliances)
GP - Space maintainers done in connection with orthodontic
treatment are included in the fee for orthodontic treatment.
GP - Repair or replacement of a space maintainer is not covered
GP - Replacement of a space maintainer could be a benefit if
additional extractions are done or to accommodate growth.
GP - Only covered on patients under 14.
GP - Space maintainer for missing primary anterior teeth or
missing permanent teeth are not covered benefits.
GP - Space maintainers fees include all teeth, clasp and rest;
however, this is only applicable to removable space maintainers.
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xD1510 space maintainer - fixed - unilateral
xD1515 space maintainer - fixed - bilateral
xD1520 space maintainer - removable - unilateral
xD1525 space maintainer - removable - bilateral
D1550 re-cement or re-bond space maintainer
Re - cementation or re- bond of a space maintainer by the same
dentist/office within 6 months is covered in the fee for the space
maintainer.
D1555 removal of fixed space maintainer.
Not covered
D2000 - D2999 III. RESTORATIVE
GP - The fee for a restoration includes services such as, but is not
limited to, slots, preparations, adhesives, etching, liners, bases,
pulp caps, local anesthesia, polishing, occlusal adjustment, caries
removal.
GP - Payment is made for restoring a surface only once within 24
month regardless of the number or combination of restorations
placed. Benefits may be allowed if done by another dental office.
The definition of the same Dentist includes providers in the same
dental office.
GP - Posterior restorations involving the proximal and occlusal
surfaces are considered one restoration for payment purposes.
D2140 amalgam - one surface, primary or permanent
D2150 amalgam - two surfaces, primary or permanent
D2160 amalgam - three surfaces, primary or permanent
D2161 amalgam - four or more surfaces, primary or permanent
Resin - Based Composite Restorations - Direct
GP - In the event an anterior proximal restoration involves a
significant portion of the labial or lingual surface, it may be
reported as 02331 or 02332, as appropriate.
GP - Preventive resin restorations are considered sealants for
payment purposes.
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GP - 2335 Involves four surfaces including incisal angle.
Resin restorations anterior
D2330 resin - based composite - one surface, anterior
D2331 resin - based composite - two surfaces, anterior
D2332 resin - based composite - three surfaces, anterior
D2335 resin - based composite - four or more surfaces or involving incisal
angle (anterior)
Resin restorations posterior
D2391 resin - based composite - one surface, posterior
D2392 resin - based composite - two surfaces, posterior
D2393 resin - based composite - three surfaces, posterior
D2394 resin - based composite - four or more surfaces, posterior
Procedure codes 02391 through 02394, resin restorations on
posterior teeth are not a covered benefit. The buccal surfaces of
bicuspids will be paid as a 2330 composite restoration. Any other
composite restoration will be paid as an Amalgam restoration. Any
additional fee is the patient’s responsibility.
Gold foil restorations
GP - For inlay restorations, composite onlays and porcelain or
ceramic substrate onlays, an optional benefit will be allowed for an
amalgam and resin restorations. The additional fee is the patient’s
responsibility.
D2410 gold foil - one surface
D2420 gold foil - two surfaces
D2430 gold foil - three surfaces
Inlay / onlay restorations
GP - For inlay restorations, composite onlays and porcelain or
ceramic substrate onlays, an optional benefit will be allowed for an
amalgam or resin restoration, according to the policies for
amalgam and resin restorations. The additional fee will be the
patient’s responsibility.
D2510 inlay - metallic - one surface
D2520 inlay - metallic - two surfaces
D2530 inlay - metallic - three or more surfaces
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The criteria for approval for Onlay - per tooth are the same as the
criteria for approval for cast crowns.
Cast restorations include all models, temporaries and other
associated procedures.
D2542 onlay - metallic-two surfaces
D2543 onlay - metallic - three surfaces
D2444 onlay - metallic - four or more surfaces
D2610 inlay - porcelain/ceramic - one surface
D2620 inlay - porcelain/ceramic - two surfaces
D2630 inlay - porcelain/ceramic - three or more surfaces
D2642 onlay - porcelain/ceramic - two surfaces
D2643 onlay - porcelain/ceramic - three surfaces
D2644 onlay - porcelain/ceramic - four or more surfaces
D2650 inlay - resin-based composite - one surface
D2651 inlay - resin-based composite - two surfaces
D2652 inlay - resin-based composite - three or more surfaces
D2662 onlay - resin-based composite - two surfaces
D2663 onlay - resin-based composite - three surfaces
D2664 onlay - resin-based composite - four or more surfaces
Crowns - single restoration only
GP - Crowns and cast restorations are considered to be an optional
benefit unless the tooth is damaged by decay or fracture to the
point that it cannot be restored by an amalgam or resin restoration.
GP - Crowns are subject to 5 years limitation for replacement
GP - Tooth preparation, temporary restorations, cement bases,
impressions, crown buildups, occlusal adjustment and local
anesthesia are considered to be included in the fee for a crown
restoration.
GP - Ceramic substrate/porcelain or cast metal crowns are not a
benefit for children under 12 years of age.
GP - Crowns for altering occlusion, improving the occlusal plane,
involving vertical dimension, replacing tooth structure lost by
attrition, erosion and abrasion (wear) or periodontal splinting are
not covered
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GP - Porcelain fused to metal crowns are not a covered benefit on
molars. An allowance will be made for the appropriate full cast
crown, and the patient is responsible for any additional cost.
r,x D2710 crown - resin - based composite (indirect)
r,x D2720 crown - resin with high noble metal
r,x D2721 crown - resin with predominantly base metal
r,x D2722 crown - resin with noble metal
r,x D2740 crown - porcelain / ceramic substrate
r,x D2750 crown - porcelain fused to high noble metal
r,x D2751 crown - porcelain fused to predominantly base metal
r,x D2752 crown - porcelain fused to noble metal
r,x D2790 crown - full cast high noble metal
r,x D2791 crown - full cast predominantly base metal
r,x D2792 crown - full cast noble metal
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 bases of the percentage of noble metal
content: high noble- Au, Pd and/or Pt> 60% (with at least 40%
Au); noble- Au, Pd and/or Pt> 25%; and predominantly base – Au,
Pd and/or Pt> 25%.
Other restorative services
D2910 re-cement or re-bond inlay, onlay, veneer or partial coverage
restoration
D2920 re-cement or re-bond crown
Re - cementation by the same dental office of covered restorations
within 6 months of initial placement is considered part of the fee
for the original procedure.
GP - Stainless steel crowns and/or resin crowns are not payable as
a temporary procedure, or to correct congenital or developmental
malformations.
D2930 prefabricated stainless steel crown-primary tooth.
(children under 14 only)
Replacement of a stainless steel crown by the same dentist/dental
office within 24 months is included in the initial crown placement.
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x D2931 prefabricated stainless steel crown-permanent tooth
(children under 14 only)
Replacement of a stainless steel crown by the same dentist/dental
office within 5 years is included in the initial crown placement.
x D2932 prefabricated resin crown
A prefabricated resin crown is a benefit only on anterior primary
teeth. (children under 14 only)
x D2933 prefabricated stainless steel crown with resin window.
A prefabricated stainless steel crown with resin window is a
benefit only on anterior primary teeth. (children under 14 only)
r D2940 protective restoration
A sedative filling includes the removal of caries and the placement
of the temporary cement. Limited to once per tooth in a 24 month
period. Pulp cap or indirect pulp cap on the same tooth is
considered a duplication of services.
r,x D2950 core buildup, including any pins when required
Substructures are only a benefit when necessary to retain a cast
restoration due to extensive loss of tooth structure from caries or
fracture and are subject to the same time limitations as cast
restorations.
Substructures are only a benefit when followed by a cast
restoration.
D2951 pin retention - per tooth, in addition to restoration
Pin retention is a benefit once per tooth when necessary and in
conjuction with a three or more surface or incisal angle restoration
on a permanent tooth when completed at the same appointment,
limited to 4 pins per tooth. Slots are considered part of the
preparation and are not paid as a separate service. As defined, this
service includes the post and core (build-up).
x D2952 post and core in addition to crown, indirectly fabricated
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A cast post and core in addition to crown is payable only on an
endodontically treated tooth. And limited to once in a 5 years
period.
x D2954 prefabricated post and core in addition to crown
A prefabricated post and core in addition to crown is payable only
on an endodontically treated tooth. Prefabricated post and cores are
not a covered benefit on teeth with crowns that will not be replaced
after endodontic therapy. Limited to once in a 5 years period.
D2955 post removal
(not in conjunction with endodontic therapy)
Not covered it is considered part of the fee for new post.
D2960 labial veneer (resin laminate) - chairside
D2961 labial veneer (resin laminate) - laboratory
D2962 labial veneer (porcelain laminate) - laboratory
Laminates are not covered. An allowance will be made for a resin
restoration and the patient is responsible for any additional cost.
D2970 temporary crown (fracture tooth)
Not covered
r D2980 crown repair necessitated by restorative material failure
Benefit for a crown repair is limited to one in 24 months on the
same tooth. Any additional fee for repairs is the patient’s
responsibility.
r D2999 unspecified restorative procedure, by report
D3000 - D3999 IV. ENDODONTICS
Pulp Capping
GP - Allowance for indirect pulp cap includes the sedative
restoration.
GP - Direct or indirect pulp caps provided on the same date as the
final restoration are considered part of a single complete
restorative procedure.
GP - Limited to once per tooth in a 24 month period.
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x D3110 pulp cap - direct (excluding final restoration)
The fee for pulp cap- direct is included in the fee for the
restoration.
x D3120 pulp cap - indirect (excluding final restoration)
The fee for a pulp cap-indirect is included in the fee for the
restoration.
Pulpotomy
x D3220 therapeutic pulpotomy (excluding final restoration) - removal of
pulp coronal to the dentinocemental junction and application of
medicament
Therapeutic pulpotomy is limited to primary teeth.
The fee for a pulpotomy on a permanent tooth is included in the
fee for the root canal.
Endodontic therapy (including treatment plan, clinical procedures,
and follow-up care)
GP - The fee for a root canal includes treatment radiograph images
and temporary restorations and all necessary diagnostic
procedures.
GP - Root canal therapy is only a covered benefit on permanent
teeth.
f,x D3310 endodontic therapy, anterior tooth (excluding final restoration)
f,x D3320 endodontic therapy, bicuspid tooth (excluding final restoration)
f,x D3330 endodontic therapy, molar (excluding final restoration)
A paste type root canal filling is not a benefit.
Palliative treatment in conjunction with root canal therapy by the
same provider is to be included in the fee for the root canal.
Unsuccessful attempts of endodontic treatment are not payable or
chargeable to the patient.
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Retreatment of root canal therapy or apical surgery by the same
dentist/dental office within 24 month is considered part of the
original procedure. Incompletely filled root canals are not payable.
Root canal therapy is not a benefit in conjunction with
overdentures. Or extruded teeth to be restored for the purpose of
improving the occlusal plane.
Endodontic retreatment
GP - By report and predetermination is suggested if patient is not
in pain.
r,fx D3346 retreatment of previous root canal therapy - anterior
r,fx D3347 retreatment of previous root canal therapy - bicuspid
r,fx D3348 retreatment of previous root canal therapy – molar
Apexification / recalcification procedures
x D3351 apexification/recalcification – initial visit (apical closure / calcific
repair of perforations, root resorption, etc.)
Apexification is only allowable on permanent teeth with
incomplete root development or for repair of a perforation.
D3352 apexification/recalcification – interim medication replacement
D3353 apexification/recalcification - final visit (includes completed root
canal therapy - apical closure/calcific repair of perforations, root
resorption, etc.)
Apicoectomy/ periapical services
x D3410 apicoectomy - anterior
x D3421 apicoectomy - bicuspid (first root)
x D3425 apicoectomy - molar (first root)
x D3426 apicoectomy (each additional root)
fx D3430 retrograde filling per root
Retrograde filling includes all retrograde procedures per root.
x D3450 root amputation - per root
Root amputation performed in conjunction with an apicoectomy is
not a separate benefit.
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Fee will be modified if done with periodontal surgery in the same
area.
D3460 endodontic endosseous implant
Not a covered benefit.
D3470 intentional reimplantation (including necessary splinting)
Intentional reimplantation is a specialized technique and therefore
is not covered.
Other endodontic procedures
D3910 surgical procedure for isolation of tooth with rubber dam
The fee for isolation of tooth with rubber dam is included in the
procedure performed.
x D3920 hemisection (including any root removal), not including root canal
therapy
A hemisection performed in conjunction with root removal or
apicoectomy is included in the fee for that service.
The fee will be modified if done with osseous surgery in the same
area.
D3950 canal preparation and fitting of performed dowel or post
Canal preparation and fitting of performed dowel or post is
included in the fee for the post or root canal.
D3999 unspecified endodontic procedure, by report
D4000 - D4999 V. PERIODONTICS
Surgical services (including usual postoperative services)
GP - Periodontal surgery includes routine post-operative care for 3
months following treatment.
GP - The fee for re-entry within three years of the original
periodontal surgery is a part of the fee for the original procedure
unless extraordinary circumstances are documented.
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GP - Radiographs and Periodontal Chart are required
GP - Quadrant fees may be prorated according to the number of
teeth treated, based on a minimum of 4 teeth per quadrant. A
maximum of 4 quadrants will be allowed.
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or
tooth bounded spaces per quadrant
(perio charting and diagnosis are required).
r D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or
tooth bounded spaces per quadrant
(by report is required).
Gingivectomy or gingivoplasty - per tooth is included in the fee for
the restorations done at the same time.
x D4240 gingival flap procedure, including root planing - four or more
contiguous teeth or tooth bounded spaces per quadrant
x D4241 gingival flap procedure, including root planing - one to three
contiguous teeth or tooth bounded spaces per quadrant
x D4245 apically positioned flap
x D4249 clinical crown lengthening - hard tissue
Crown lengthening is payable per site and not payable per tooth
when adjacent teeth are included. This procedure is a benefit only
when bone is removed. It is not payable if done on the same day as
the crown preparation.
x D4260 osseous surgery (including elevation of a full thickness flap and
closure) – four or more contiguous teeth or tooth bounded spaces
per quadrant
Osseous surgery includes the fee for the distal wedge. Limited to
once every 36 month.
x D4261 osseous surgery (including elevation of a full thickness flap and
closure) – one to three contiguous teeth or tooth bounded spaces
per quadrant
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Osseous surgery includes the fee for the distal wedge. Limited to
once every 36 month.
r,x D4263 bone replacement graft-first site in quadrant
Covered only in specific group. See PPO table.
r,x D4264 bone replacement graft-each additional site in quadrant
Covered only in specific group. See PPO table.
r,x D4266 guided tissue regeneration- resorbable barier, per site
Covered only in specific group. See PPO table.
r,x D4267 guided tissue regeneration – nonresorbable barrier, per site
(includes membrane removal)
Covered only in specific group. See PPO table.
x D4270 pedicle soft tissue graft procedure
x D4273 subepithelial connective tissue graft procedures, per tooth
x D4274 distal or proximal wedge procedure (when not preformed in
conjunction with surgical procedures in the same anatomical area)
Included in the fee for other periodontal surgery.
x D4277 free soft tissue graft procedure (including donor site surgery), first
tooth or edentulous tooth position in graft
x D4278 free soft tissue graft procedure (including donor site surgery), each
additional contiguous tooth or edentulous tooth position in same
graft site
Non – Surgical Periodontal Services
D4320 provisional splinting-intracoronal
Splinting is not a covered benefit.
D4321 provisional splinting - extracoronal
x D4341 periodontal scailing and root planning- four or more teeth per
quadrant
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x D4342 periodontal scailing and root planning - one to three teeth per
quadrant
The time limitation for prophylaxis is established by contract.
Additional prophylaxis are optional and may be charged to the
patient. 04910 is counted toward the contract limitation for
prophylaxis.
A prophylaxis done on the same date as a periodontal prophylaxis,
curettage, scaling or root planing is considered to be part of and
included in those procedures.
A maximum of 4 different quadrants of root planning are allowed
within 24 months.
Surgical curettage and root planing are considered components of a
single procedure. Payment is made for curettage.
Periodontal root planning, per quadrant, must be completed within
three months of the beginning of periodontal therapy. Radiographs
are required.
r,xD4355 full mouth debridement to enable comprehensive evaluation and
diagnosis
Allowed once in a lifetime. An adult prophylaxis is subject to
special consideration for a difficult prophylaxis, by report.
D4381 localized delivery of antimicrobial agents via controlled release
vehicle into diseased crevicular tissue, per tooth
Not covered
Other periodontal services
D4910 periodontal maintenance
Periodontal prophylaxis count toward the prophylaxis limitations.
Procedure 04910 includes the examination.
rD4999 unspecified periodontal procedures, by report.
D5000 - D5899 VI. PROSTHODONTICS (REMOVABLE)
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GP - Any characterization, staining, overdentures or metal bases
are specialized techniques and an allowance will be made for a
conventional denture. Any additional fee is the patient’s
responsibility.
GP - Full or partial dentures includes any reline/rebase, adjustment
or repair required within 6 months of delivery; except in the case
of immediate denture, relines may be a benefit after 3 months.
GP - Prosthetics (removable) are subject to a 5 year limitation for
replacement.
Complete dentures (including routine post - delivery care)
x D5110 complete denture - maxillary
x D5120 complete denture - mandibular
x D5130 immediate denture - maxillary
x D5140 immediate denture - mandibular
GP - A fixed bridge and partial denture are not benefits in the
same arch. Benefit is limited to the allowance for a partial denture.
GP - Fixed bridges or removable cast partials are not a benefit for
patients under age 16. (Contract limitation)
GP - Partial dentures are subject to a 5 year limitation for
replacement.
GP - Valplast partials do not fix the description of codes 5211 thru
5281. An allowance will be made for a 5211 or 5212. Any
additional fee is the patients responsibility.
Partial Dentures (Including Routine Post – Delivery Care)
x D5211 maxillary partial denture- resin base (including any conventional
clasp, rest and teeth)
x D5212 mandibular partial denture-resin base (including any conventional
clasp, rest and teeth)
x D5213 maxillary partial denture - cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
x D5214 mandibular partial denture - cast metal framework with resin
denture bases (including any conventional clasps, rests and teeth)
x D5281 removable unilateral partial denture-one piece cast metal
(including clasps and teeth)
Adjustments to dentures
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GP - Full or partial dentures include any adjustment or repair
required within 6 months of delivery.
GP - Adjustments to dentures are limited to 2 adjustments per
denture per 12 months.
GP - Denture adjustments are covered in the basic level benefit.
D5410 adjust complete denture - maxillary
D5411 adjust complete denture - mandibular
D5421 adjust partial denture - maxillary
D5422 adjust partial denture – mandibular
Repairs to Complete Dentures
r D5510 repair broken complete denture base
r D5520 replace missing or broken teeth - complete denture (each tooth)
Repairs to partial dentures
GP - Fee for repair of a partial denture cannot exceed one-half of
the fee for a new appliance.
r D5610 repair resin denture base
r D5620 repair cast framework
r D5630 repair or replace broken clasp
r D5640 replace broken teeth-per tooth
r D5650 add tooth to existing partial denture
r D5660 add clasp to existing partial denture
Denture rebase procedures
GP - Rebase is a benefit once in 36 month period.
GP - Repair cast framework
GP - Rebase includes adjustments requires within 6 month of
delivery.
GP - Denture rebases are covered under the prosthodontic level.
D5710 rebase complete maxillary denture
D5711 rebase complete mandibular denture
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D5720 rebase maxillary partial denture
D5721 rebase mandibular partial denture
Denture reline procedure
GP - Relines are benefits once in a 36 month period.
GP - Relines includes adjustments required within 6 months of
delivery
GP - Relines are covered under prosthodontic level
D5730 reline complete maxillary denture (chairside)
D5731 reline complete mandibular denture (chairside)
D5740 reline maxillary partial denture (chairside)
D5741 reline mandibular partial denture (chairside)
D5750 reline complete maxillary denture (laboratory)
D5751 reline complete mandibular denture (laboratory)
D5760 reline maxillary partial denture (laboratory)
D5761 reline mandibular partial denture (laboratory)
Interim Prostheesis
D5810 interim complete denture (maxillary)
D5811 interim complete denture (mandibular)
Temporary complete denture is not a benefit
r,x D5820 interim partial denture (maxillary)
r,x D5821 interim partial denture (mandibular)
Temporary partial-stayplate denture 05820 or 05821 is a benefit
only when replacing permanent anterior teeth during the healing
period.
Other Removable Prosthetic Services
D5850 tissue conditioning, maxillary
D5851 tissue conditioning, mandibular
Tissue conditioning, 05850 or 05851 is not a benefit if performed
on the same day the denture is delivered or a reline/rebase is
provided.
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Tissue conditioning is not a benefit more than twice per denture
unit in 36 months.
r D5862 precision attachment, by report
A precision attachment is not a benefit. It is a specialized
technique.
r D5863 overdenture – complete maxillary, by report
r D5864 overdenture – partial maxillary, by report
r D5865 overdenture – complete mandibular, by report
r D5866 overdenture – partial mandibular, by report
Overdentures are considered a specialized technique. An allowance
will be made for a conventional denture.
r D5899 unspecified removable prosthodontic procedure, by report
D5900 - D5999 VII. MAXILLOFACIAL PROSTHETICS
GP - Maxillofacial prosthetics are not a covered benefit.
D5911 facial moulage (sectional)
D5912 facial moulage (complete)
D5913 nasal prosthesis
D5914 auricular prosthesis
D5915 orbital prosthesis
D5916 ocular prosthesis
D5919 facial prosthesis
D5922 nasal septal prosthesis
D5923 ocular prosthesis, interim
D5924 cranial prosthesis
D5925 facial augmentation implant prosthesis
D5926 nasal prosthesis, replacement
D5927 auricular prosthesis, replacement
D5928 orbital prosthesis, replacement
D5929 facial prosthesis, replacement
Intraoral prostheses-acquired defects
D5931 obturator prosthesis, surgical
D5932 obturator prosthesis, definitive
D5933 obturator prosthesis, modification
D5934 mandibular resection prosthesis with guide flange
D5935 mandibular resection prosthesis without guide flange
23
D5936 obturator prosthesis, interim
D5937 trismus appliance (not for TMD treatment)
Intraoral prostheses- congenital defects
D5951 feeding aid
D5952 speech aid prosthesis, pediatric
D5953 speech aid prosthesis, adult
D5954 palatal augmentation prosthesis
D5955 palatal lift prosthesis, definitive
D5958 palatal lift prosthesis, interim
D5959 palatal lift prosthesis, modification
D5960 speech aid prosthesis, modification
Treatment Prostheses
D5982 surgical stent
D5983 radiation carrier
D5984 radiation shield
D5985 radiation cone locator
D5986 fluoride gel carrier
D5987 commissure splint
D5988 surgical splint
r D5999 unspecified maxillofacial prosthesis, by report
D6000 - D6199 VII. IMPLANT SERVICES
GP - Implants services covered only in specific groups. See PPO special
group table.
Surgical Services
D6010 surgical placement of implant body: endosteal implant
D6040 surgical placement: eposteal implant
D6050 surgical placement: transosteal implant
r D6100 implant removal, by report
Implant Supported Prosthetics
D6055 connecting bar – implant supported or abutment supported
x D6058 abutment supported porcelain/ceramic crown
Covered only in specific group. See PPO table.
24
x D6059 abutment supported porcelain fused to metal crown (high noble
metal)
Covered only in specific group. See PPO table.
x D6061 abutment supported porcelain fused to metal crown (noble metal)
Covered only in specific group. See PPO table.
x D6062 abutment supported cast metal crown (high noble metal)
Covered only in specific group. See PPO table.
x D6064 abutment supported cast metal crown (noble metal)
Covered only in specific group. See PPO table.
x D6065 implant supported porcelain/ceramic crown
Covered only in specific group. See PPO table.
x D6066 implant supported porcelain fused to metal crown (titanium,
titanium alloy, high noble metal)
Covered only in specific group. See PPO table.
x D6067 implant supported metal crown (titanium, titanium alloy, high
noble metal)
Covered only in specific group. See PPO table.
x D6068 abutment supported retainer for porcelain/ceramic FPD
Covered only in specific group. See PPO table.
x D6069 abutment supported retainer for porcelain fused to metal FPD (high
noble metal)
Covered only in specific group. See PPO table.
x D6070 abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
Covered only in specific group. See PPO table.
x D6071 abutment supported retainer for porcelain fused to metal FPD
(noble metal)
25
Covered only in specific group. See PPO table.
x D6072 abutment supported retainer for cast metal FPD (high noble metal)
Covered only in specific group. See PPO table.
x D6073 abutment supported retainer for cast metal FPD (predominantly
base metal)
Covered only in specific group. See PPO table.
x D6074 abutment supported retainer for cast metal FPD (noble metal)
Covered only in specific group. See PPO table.
x D6075 implant supported retainer for ceramic FPD
Covered only in specific group. See PPO table.
x D6076 implant supported retainer for porcelain fused to metal FPD
(titanium, titanium alloy, or high noble metal)
Covered only in specific group. See PPO table.
x D6077 implant supported retainer for cast metal FPD (titanium, titanium
alloy, or high noble metal)
Covered only in specific group. See PPO table.
Other Implant Services
D6080 implant maintenance procedures when prostheses are removed and
reinserted, including cleansing of prostheses and abutments
r D6090 repair implant supported prosthesis, by report
r D6095 repair implant abutment, by report
r D6199 unspecified implant procedure, by report
D6200 - D6999 IX. PROSTHODONTICS, fixed
GP - Full mouth or panorex is required
GP - Payment will be based on the number of pontics necessary
for the space, not to exceed the normal complement of teeth.
26
GP - A fixed bridge and partial denture are not benefits in the
same arch. Benefit is limited to the allowance for a partial denture.
GP - Fixed prosthodontics are not a benefit for children under 16
years of age.
GP- Porcelain and resin inlay bridges are not covered benefits.
GP - Prosthetics (fixed) are subject to a 5 year limitation for
replacement.
GP - Porcelain fused to metal crowns for posteriors to the second
bicuspid position are optional. An allowance will be made for the
appropriate cast crown, and the patient is responsible for the
additional cost.
Fixed partial denture pontics
x D6210 pontic - cast high noble metal
x D6211 pontic - cast predominantly base metal
x D6212 pontic - cast noble metal
x D6214 pontic – titanium
Covered only in specific group. See PPO table.
x D6240 pontic - porcelain fused to high noble metal
x D6241 pontic - porcelain fused to predominantly base metal
x D6242 pontic - porcelain fused to noble metal
x D6250 pontic - resin with high noble metal
x D6251 pontic - resin with predominantly base metal
x D6252 pontic - resin with noble metal
Fixed partial denture retainers-inlays/onlays
x D6545 retainer - cast metal for resin bonded fixed prosthesis
A three unit acid-etch bonded bridge is a benefit only for replacing
a single tooth. Cantilevered bridges with a bonded wing retainer in
combination with a conventional retainer or posterior acid etch
bonded bridges are not a covered benefits.
x D6604 inlay - cast predominantly base metal, two surfaces
x D6605 inlay - cast predominantly base metal, three or more surfaces
x D6606 inlay - cast noble metal, two surfaces
Covered only in specific group. See PPO table.
27
x D6607 inlay - cast noble metal, three or more surfaces
Covered only in specific group. See PPO table.
Fixed partial denture retainers- crowns
x D6720 crown - resin with high noble metal
x D6721 crown - resin with predominantly base metal
x D6722 crown - resin with noble metal
x D6750 crown - porcelain fused to high noble metal
x D6751 crown - porcelain fused to predominantly base metal
x D6752 crown - porcelain fused to noble metal
x D6780 crown - 3/4 cast high noble metal
x D6781 crown - 3/4 cast predominantly base metal
Covered only in specific group. See PPO table.
x D6782 crown - 3/4 cast noble metal
Covered only in specific group. See PPO table.
x D6790 crown - full cast high noble metal
Covered only in specific group. See PPO table.
x D6791 crown - full cast predominantly base metal
Covered only in specific group. See PPO table.
x D6792 crown - full cast noble metal
x D6794 crown – titanium
Covered only in specific group. See PPO table.
Other fixed partial denture services
D6920 connector bar
Not covered
r D6930 re-cement or re-bond fixed partial denture
Re - cementation or re – bond of a bridge by the same dental office
within 6 months of the seating date is part of the fee for the
original procedure.
28
Re - cementation or bond of a bridge is a benefit limited to once
per year.
D6940 stress breaker
Not covered, it is considered a specialized technique.
D6950 precision attachment
Not covered, it is consider a specialized technique.
GP - Cast post and cores, prefabricated posts and cores and crown
build-ups have the same limitations as 2950, 2952, 2954.
D6975 coping
Coping is considered a specialized technique and is not covered.
r,x D6980 fixed partial denture repair necessitated by restorative material
failure
Fee for repair of a fixed/partial denture cannot exceed one-half of
the fee for a new appliance.
r D6999 unspecified fixed prosthodontic procedure, by report.
D7000 - D7999 X. ORAL AND MAXILLOFACIAL SURGERY
GP - The fee for all oral and maxillofacial surgery includes routine
postoperative care.
GP - Extractions Includes local anesthesia, suturing, if needed, and
routine postoperative care.
GP - Unsuccessful attempts at extractions are not payable or
chargeable to the patient.
D7111 extraction, coronal remnants - deciduous tooth
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
GP - Impaction codes are based on anatomical position rather than
the surgical procedure necessary for removal.
29
GP - Unsuccessful attempts at extractions are not payable or
chargeable to the patient.
x D7210 surgical removal of erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of mucoperiosteal flap
if indicated
x D7220 removal of impacted tooth- soft tissue
Occlusal surface of tooth covered by soft tissue; requires
mucoperiosteal flap elevation.
x D7230 removal of impacted tooth - partially bony
Part of crown covered by bone; requires mucoperiosteal flap
elevation and bone removal.
x D7240 removal of impacted tooth - completely bony
Most or all of crown covered by bone; requires mucoperiosteal flap
elevation and bone removal.
x D7250 surgical removal of residual tooth roots (cutting procedure)
Includes cutting of soft tissue and bone, removal of tooth structure,
and closure.
Fee for root recovery is included in the fee for surgical extraction if
done by the same dentist/dental office.
Other surgical procedures
GP - All surgical procedures include routine postoperative care.
x D7260 oroantral fistula closure
r,x D7270 tooth reimplantation and/or stabilization of accidentally evulsed or
displaced tooth
Includes postoperative care and removal of splint.
D7272 tooth transplantation (includes reimplantation from one site to
another and splinting and/or stabilization)
Not Covered. It is considered a specialized technique.
x D7280 surgical access of an unerupted tooth
x D7283 placement of device to facilitate eruption of impacted tooth
Covered only in specific group. See PPO table.
30
x D7285 incisional biopsy of oral tissue-hard (bone, tooth)
r D7286 incisional biopsy of oral tissue-soft
Biopsy of oral tissue is included in the fee for other surgical
services in the same area. A pathological report must be included.
Biopsy of oral tissue is only payable for oral structures.
r,x D7290 surgical repositioning of teeth
Surgical repositioning of teeth is a benefit only if orthodontic
coverage is present.
r D7291 transseptal fiberotomy / supra crestal fiberotomy, by report
Transseptal fiberotomy is a benefit only if orthodontic coverage is
present.
Alveloplasty-surgical preparation of ridge
GP - Alveloplasty/ alveolectomy performed for less than five
adjacent tooth sockets is not elegible for benefits.
r,x D7310 alveoloplasty in conjunction with extractions - four or more teeth
or tooth spaces, per quadrant
Alveoloplasty is included in the fee for the surgical extractions.
r,x D7311 alveoloplasty in conjunction with extractions - one to three teeth or
tooth spaces, per quadrant
Covered only in specific group. See PPO table.
r D7320 alveoloplasty not in conjunction with extractions - four or more
teeth or tooth spaces, per quadrant
r D7321 alveoloplasty not in conjunction with extractions - one to three
teeth or tooth spaces, per quadrant
Covered only in specific group. See PPO table.
31
Vestibuloplasty
GP - All procedures are by report and subject to coverage under
medical insurance.
r D7340 vestibuloplasty - ridge extension (secondary epithelialization)
r D7350 vestibuloplasty - ridge extension (including soft tissue grafts,
muscle reattachments, revision of soft tissue attachment and
management of hypertrophied and hyperplastic tissue)
Surgical excision of soft tissue lesions
GP - All procedures are by report and subject to coverage under
medical insurance.
r D7410 excision of benign lesion up to 1.25 cm
r D7465 destruction of lesion(s) by physical or chemical method, by report
Covered only in specific group. See PPO table.
Surgical excision of intra – osseous lesions
GP - All procedures are by report and are subject to coverage
under medical insurance.
r D7440 excision of malignant tumor - lesion diameter up to 1.25 cm
r D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm
r D7450 removal of benign odontogenic cyst or tumor - lesion diameter up
to 1.25 cm
r D7451 removal of benign odontogenic cyst or tumor - lesion diameter
greater than 1.25 cm
r D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter
up to 1.25 cm
r D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter
greater than 1.25 cm
32
Excision of bone tissue
GP - All procedures are by report and are subject to coverage
under medical insurance.
D7490 radical resection of maxilla or mandible
r D7471 removal of lateral exostosis (maxilla or mandible)
r D7472 removal of torus palatinus
Covered only in specific group. See PPO table.
r D7473 removal of torus mandibularis
Covered only in specific group. See PPO table.
Surgical incision
GP - All procedures are by report and are subject to coverage
under medical insurance.
r D7510 incision and drainage of abscess-intraoral soft tissue
Surgical incision is included in the fee for endodontics, extractions,
or other definitive service.
r D7520 incision and drainage of abscess-extraoral soft tissue
Incision and drainage of abscess-extraoral soft tissue is a benefit
only if dentally related infection is present.
r D7530 removal of foreign body from mucosa, skin, or subcutaneous
alveolar tissue
r D7540 removal of reaction producing foreign bodies, musculoskeletal
system
D7550 partial ostectomy / sequestrectomy for removal of non-vital bone
D7560 maxillary sinusotomy for removal of tooth fragment or foreign
body
Treatment of fractures-simple
33
GP - All procedures are by report and are subject to coverage
under medical insurance.
r D7610 maxilla - open reduction (teeth immobilized if present)
Covered only in specific group. See PPO table.
r D7620 maxilla - closed reduction (teeth immobilized if present)
Covered only in specific group. See PPO table.
r D7630 mandible - open reduction (teeth immobilized if present)
Covered only in specific group. See PPO table.
r D7640 mandible - closed reduction (teeth immobilized if present)
Covered only in specific group. See PPO table.
r D7650 malar and / or zygomatic arch-open reduction
Covered only in specific group. See PPO table.
r D7660 malar and / or zygomatic arch-closed reduction
Covered only in specific group. See PPO table.
r D7670 alveolus closed reduction may include stabilization of teeth
Covered only in specific group. See PPO table.
D7680 facial bones - complicated reduction with fixation and multiple
surgical approaches
Treatment of fractures-compound
GP - All procedures are by report and are subject to coverage
under medical insurance.
D7710 maxilla - open reduction
D7720 maxilla - closed reduction
D7730 mandible - open reduction
D7740 mandible - closed reduction
D7750 malar and / or zygomatic arch-open reduction
34
D7760 malar and / or zygomatic arch-closed reduction
D7770 alveolus - open reduction stabilization of teeth
D7780 facial bones - complicated reduction with fixation and multiple
surgical approaches
Reduction of dislocation and management of other temporomandibular joint
dysfunctions. Procedures which are an integral part of a primary procedure should not be
reported separately
GP - All procedures except D7880 and D7899 are not covered
D7810 open reduction of dislocation
D7820 closed reduction of dislocation
D7830 manipulation under anesthesia
D7840 condylectomy
D7850 surgical discectomy, with / without implant
D7852 disc repair
D7854 synovectomy
D7856 myotomy
D7858 joint reconstruction
D7860 arthrotomy
D7865 arthroplasty
D7870 arthrocentesis
D7872 arthroscopy - diagnosis, with or without biopsy
D7873 arthroscopy - surgical: lavage and lysis of adhesions
D7874 arthroscopy - surgical: disc repositioning and stabilization
D7875 arthroscopy - surgical: synovectomy
D7876 arthroscopy - surgical: discectomy
D7877 arthroscopy - surgical: debridement
r D7880 occlusal orthotic device, by report
Covered only in specific group. See PPO table.
r D7899 unspecified TMD therapy, by report
Covered only in specific group. See PPO table.
Repair of traumatic wounds
GP - Repair of traumatic wounds is limited to oral structures.
r D7910 suture of recent small wounds up to 5 cm
Complicated suturing (reconstruction requiring delicate handling of tissues and
wide undermining for meticulous closure)
GP - Complicated suturing is limited to oral structures.
35
r D7911 complicated suture - up to 5 cm
r D7912 complicated suture - greater than 5 cm
Other repair procedures
GP - All procedures except 07960, 07970 and 07971 are not
covered, the others are subject to coverage under medical
insurance.
D7920 skin grafts (identity defect covered, location and type of graft)
D7940 osteoplasty - for orthognathic deformities
D7941 osteotomy - mandibular rami
D7943 osteotomy - mandibular rami with bone graft; includes obtaining
the graft
D7944 osteotomy - segmented or subapical
D7945 osteotomy - body of mandible
D7946 LeFort I (maxilla - total)
D7947 LeFort I (maxilla - segmented)
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface
hypoplasia or retrusion) - without bone graft
D7949 LeFort II or LeFort III - with bone graft
D7950 osseous, osteoperiosteal, or cartilage graft of the mandible or
maxilla - autogenous or nonautogenous, by report
D7955 repair of maxillofacial soft and/or hard tissue defects
D7960 frenulectomy - also known as frenectomy or frenotomy - separate
procedure not incidental to another procedure
Frenulectomy is included in the fee for other surgical procedure (s)
in the area.
D7970 excision of hyperplastic tissue - per arch
Excision of hyperplastic tissue is included in the fee for other
surgical procedure (s) in the area.
D7971 excision of pericoronal gingiva
Excision of pericoronal gingival is included in the fee for other
surgical procedure (s) in the area.
D7980 sialolithotomy
D7981 excision of salivary gland, by report
D7982 sialodochoplasty
D7983 closure of salivary fistula
D7990 emergency tracheotomy
D7991 coronoidectomy
D7995 synthetic graft - mandible or facial bones, by report
36
D7996 implant - mandible for augmentation purposes (excluding alveolar
ridge), by report
D7999 unspecified oral surgery procedure, by report
D8000 - D8999 XI. ORTHODONTICS
GP - Pre-certification is required for orthodontic treatment.
GP - Extension of orthodontic treatment are not a covered benefits.
GP - Treatments terms will only be paid from 18 thru 36 months.
GP - Orthodontic benefits are limited to children of at least 6 years
of age, or up to contract limitations.
Limited orthodontic treatment
* D8010 limited orthodontic treatment of the primary dentition
* D8020 limited orthodontic treatment of the transitional dentition
* D8030 limited orthodontic treatment of the adolescent dentition
* D8040 limited orthodontic treatment of the adult dentition
Interceptive orthodontic treatment
* D8050 interceptive orthodontic treatment of the primary dentition
* D8060 interceptive orthodontic treatment of the transitional dentition
Comprehensive orthodontic
* 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 therapy
* D8220 fixed appliance therapy
Other Orthodontic Services
37
*D8660 pre-orthodontic treatment examination to monitor growth and
development
* D8670 periodic orthodontic treatment visit (as part of contract)
* D8680 orthodontic retention (removal of appliances, construction and
placement of retainer(s)
* D8690 orthodontic treatment (alternative billing to a contract fee)
* D8691 repair of orthodontic appliance
* D8694 repair of fixed retainers, includes reattachment
r,* D8999 unspecified orthodontic procedure, by report
D9000 - D9999 XII. ADJUNCTIVE GENERAL SERVICES
Unclassified treatment
r D9110 palliative (emergency) treatment of dental pain-minor procedures
Palliative treatment is not a benefit when any other service is done
on the same date except limited radiographs and test necessary to
diagnose the emergency condition.
Emergency palliative treatment is payable on a per visit basis, once
on the same date. The diagnosis and all procedures necessary for
relief of pain are included.
Palliative treatment in conjunction with root canal therapy by the
same dentist is included in the fee for the root canal.
Documentation should be submitted with claims for this procedure.
If the procedure performed is a procedure with a specific code
established by the ADA and / or CDT, it will be processed
accordingly and not as a 9110.
Anesthesia
GP- All procedures are not covered except D9220.
D9210 local anesthesia not in conjunction with operative or surgical
procedures
D9211 regional block anesthesia
D9212 trigeminal division block anesthesia
38
D9215 local anesthesia in conjunction with operative or surgical
procedures
r D9220 deep sedation / general anesthesia - first 30 minutes
The fee for general anesthesia is a benefit only when administered
by a properly licensed dentist in a dental office in conjunction with
multiple impactions or surgery.
D9230 inhalation of nitrous oxide/analgesia, anxiolysis
Analgesia is not a covered benefit.
Professional consultation
r D9310 consultation - diagnostic service provided by dentist or physician
other than requesting dentist or physician
See D0160
Professional visits
D9410 house / extended care facility call
Not Covered
r D9420 hospital or ambulatory surgical center call
Covered only in specific group. See PPO table.
D9430 office visit for observation (during regularly schedule hours)-no
other services performed
Not Covered
D9440 office visit - after regularly schedule hours
Not Covered
Drugs
D9610 therapeutic parenteral drug, single administration
Not Covered
39
r D9630 other drugs and/or medicaments, by report
Covered only in specific group. See PPO table.
Miscellaneous Services
r D9910 application of desensitizing medicament
Application of desensitizing medicaments is not a covered benefit.
D9920 behavior management, by report
Not Covered
r D9930 treatment of complications (post-surgical) - unusual circumstances,
by report
Treatment of routine complications is not a covered benefit unless
performed by a dentist other than the treating dentist.
r D9940 occlusal guard, by report
Covered only in specific group. See PPO table.
D9941 fabrication of athletic mouthguard
Not Covered
D9950 occlusion analysis - mounted case
Not Covered
r D9951 occlusion adjustment - limited
Covered only in specific group. See PPO table.
r D9952 occlusion adjustment-complete
Covered only in specific group. See PPO table.
D9970 enamel microabrasion
Not Covered
r D9999 unspecified adjunctive procedure, by report.