CDT 2022

Code on Dental Procedures and

Nomenclature
Arkansas Procedure Guidelines Analysis

Revised: September 2021

Table of Contents
Diagnostic Services..................................................................................................................................... 3

Preventive Services ................................................................................................................................... 12

Restorative Services ................................................................................................................................. 14

Endodontic Services ................................................................................................................................. 23

Please note the following: ........................................................................................................................ 23

Periodontal Services ................................................................................................................................. 28

Procedure Billing Guidelines ................................................................................................................... 28

Payment for Surgical Services ................................................................................................................ 28
Prosthodontics, Removable ..................................................................................................................... 33

Coverage ............................................................................................................................................... 44
Implant Services .................................................................................................................................. 44
Prosthodontics, Fixed ............................................................................................................................... 53

Benefits ................................................................................................................................................... 53
When Services Are Non-Covered ........................................................................................................... 53
Oral and Maxillofacial Surgery ................................................................................................................. 58

Orthodontic Services ................................................................................................................................ 76

Orthodontic Benefit Administration ......................................................................................................... 76

How to Submit Claims - Please follow these guidelines when submitting claims for orthodontic
treatment: ................................................................................................................................................ 76
Adjunctive Service..................................................................................................................................... 78

Specific Benefit Limitations...................................................................................................................... 85

Integral Services ..................................................................................................................................... 85

Service Limitations .................................................................................................................................. 86
Excluded Services................................................................................................................................... 87

i
Diagnostic Services

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

CLINICAL ORAL EVALUATIONS: One evaluation code may be billed per dentist per date of service. Evaluations, including diagnosis and treatment
planning, are the responsibility of the dentist. A dentist must complete all evaluations.

D0120 Periodic oral evaluation Twice per calendar year None

Once per calendar year, per patient, per
D0140 Limited oral evaluation: problem-focused None
dentist
Oral evaluation for a patient less than 3 years of age
D0145 Twice per calendar year None
and counseling with primary caregiver
Once in a 24 month period, per patient,
per dentist. Additional exams by the same
Comprehensive oral evaluation, new or established
D0150 dentist within the twenty four month None
patient
period, change code to D0120 which is
subject to the frequency limit for D0120.
Detailed, extensive oral evaluation: problem-focused, Once per calendar year, per patient, per
D0160 None
by report dentist
Re-evaluation: limited, problem focused (established
D0170 Not a covered benefit None
patient, not post-operative visit)
D0171 Re-evaluation-post operative visit Not a covered benefit None
Comprehensive periodontal evaluation: new or Once per patient per dentist per calendar
D0180 None
established patient year;
PRE-DIAGNOSTIC SERVICES
Screening of a patient: A screening, including state or
D0190 federally mandated screenings, to determine an Not a covered benefit None
individual’s need to be seen by a dentist for diagnosis

3
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Assessment of a patient: A limited clinical inspection

that is performed to identify possible signs of oral or
D0191 Not a covered benefit None
systemic disease, malformation, or injury, and the
potential need for referral for diagnosis and treatment

DIAGNOSTIC IMAGING: Image Capture With Interpretation; Should be taken only 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.

Intraoral complete series intraoral - complete series of

D0210 Once in a 5 year period None
radiographic images

No limit; panoramic radiograph (D0330)

reported with non-itemized charges for the
D0220 Intraoral periapical – first radiographic image. same provider and same DOS as None
periapical radiograph will merge to the
panoramic radiograph

No limit; panoramic radiograph (D0330)

reported with non-itemized charges for the
Intraoral periapical – each additional radiographic
D0230 same provider and sameDOS as None
image
periapical radiograph will merge to the
panoramic radiograph

D0240 Intraoral occlusal radiographic image No limitation Arch identification

D0250 Extraoral, 2D radiographic image No limitation None
D0251 Extra-oral posterior dental radiographic image Not covered None
D0270 Bitewing – single radiographic image No limitation None

Once per calendar year, except twice per

calendar yearfor dependent child through
D0272 Bitewings – two radiographic images age 18 None

4
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One occurrence of D0272, D0273, D0274

D0273 Bitewings – three radiographic images or D0277 in a calendar year over the age None
of 18

One occurrence of D0272, D0273, D0274

D0274 Bitewings – four radiographic images or D0277 in a calendar year over the age None
of 18

One occurrence of D0272, D0273, D0274

D0277 Vertical bitewings – 7 to 8 radiographic images or D0277 in a calendar year over the age None
of 18

D0310 Sialography Not a covered benefit None

Temporomandibular joint arthrogram, including
D0320 Not a covered benefit None
injection
Other temporomandibular joint radiographic image, by
D0321 Not a covered benefit None
report
D0322 Tomographic survey Not a covered benefit None
D0330 Panoramic radiographic image Once in a 5 year period None
D0340 Cephalometric radiographic image Once per lifetime with orthodontic benefit None

2D oral/facial photographic images obtained

D0350 Not a covered benefit None
intraorally or extraorally

D0351 3D photographic image Not a covered benefit None

Cone beam CT capture and interpretation with limited

D0364 field of view – less than one whole jaw Not a covered benefit None

5
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Cone beam CT capture and interpretation with field of

D0365 Not a covered benefit None
view of one full dental arch - mandible

Cone beam CT capture and interpretation with field of

D0366 view of one full dental arch – maxilla, with or without Not a covered benefit None
cranium

Cone beam CT capture and interpretation with field of

D0367 view of both jaws, with or without cranium Not a covered benefit None

Cone beam CT capture and interpretation for TMJ

D0368 Not a covered benefit None
series including two or more exposures

D0369 Maxillofacial MRI capture and interpretation Not a covered benefit None
D0370 Maxillofacial ultrasound capture and interpretation Not a covered benefit None
D0371 Sialoendoscopy capture and interpretation Not a covered benefit None
IMAGE CAPTURE ONLY: Capture by a Practitioner Not Associated with Interpretation and Report

Cone bean CT image capture with limited field of view

D0380 Not a covered benefit None
– less than one whole jaw

Cone beam CT capture and interpretation with field of

D0381 Not a covered benefit None
view of one full dental arch - mandible

Cone beam CT capture and interpretation with full

D0382 Not a covered benefit None
dental arch – maxilla, with or without cranium

Cone beam CT capture and interpretation with field of

D0383 Not a covered benefit None
view of both jaws, with or without cranium

6
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Cone beam CT capture and interpretation for TMJ

D0384 Not a covered benefit None
series including two or more exposures

D0385 Maxillofacial MRI capture and interpretation Not a covered benefit None
D0386 Maxillofacial ultrasound capture and interpretation Not a covered benefit None
INTERPRETATION AND REPORT ONLY: Interpretation and Report by Practitioner not Associated with Image
Capture.

Interpretation of diagnostic image by practitioner not

D0391 Not a covered benefit None
associated with capture of image, including report

D0393 Treatment simulation using 3D image volume Not a covered benefit None

Digital subtraction of two or more images or image

D0394 Not a covered benefit None
volumes of the same modality

Fusion of two or more 3D image volumes of one or

D0395 Not a covered benefit None
more modalities

TESTS AND EXAMINATIONS

D0411 HbA1c in-office point of service testing Not a covered benefit None
Blood glucose level test—in-office using a glucose
D0412 Not a covered benefit None
meter

7
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Laboratory processing of microbial specimen to

D0414 include culture and sensitivity studies, preparation, Not a covered benefit None
and transmission of written report

Collection of microorganisms for culture and

D0415 Not a covered benefit None
sensitivity

D0416 Viral Culture Not a covered benefit None

Collection and preparation of saliva sample for

D0417 Not a covered benefit None
laboratory diagnostic testing

D0418 Analysis of saliva sample Not a covered benefit None

D0419 Assessment of salivary flow by measurement Not a covered benefit None

Collection and preparation of genetic sample material

D0422 Not a covered benefit None
for laboratory analysis and report

Genetic test for susceptibility to diseases – specimen

D0423 Not a covered benefit None
analysis
D0425 Caries susceptibility tests Not a covered benefit None

Adjunctive pre-diagnostic test that aids in detection of

Covered for participants in Dental Xtra
mucosal abnormalities including premalignant and
D0431 who have been diagnosed with oral None
malignant lesions; does not include cytology or biopsy
cancer
procedures

D0460 Pulp vitality tests Once per visit None

D0470 Diagnostic casts No limitation None

8
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

ORAL PATHOLOGY LABORATORY

Accession of tissue, gross examination, including

D0472 Not a covered benefit None
preparation and transmission of written report

Accession of tissue, gross and microscopic

D0473 examination, preparation and transmission of written Not a covered benefit None
report

Accession of tissue, gross and microscopic

examination, including assessment of surgical
D0474 Not a covered benefit None
margins for presence of disease, preparation and
transmission of written report

D0475 Decalcification procedure Not a covered benefit None

D0476 Special stains for microorganisms Not a covered benefit None
D0477 Special stains, not for microorganisms Not a covered benefit None
D0478 Immunohistochemical stains Not a covered benefit None
D0479 Tissue in-site hybridization, including interpretation Not a covered benefit None

Processing and interpretation of exfoliative cytologic

D0480 smears, including preparation and transmission of Not a covered benefit None
written report

D0481 Electron microscopy Not a covered benefit None

D0482 Direct immunofluorescence Not a covered benefit None

D0483 Indirect immunofluorescence Not a covered benefit None

D0484 Consultation on slides prepared elsewhere Not a covered benefit None

9
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Consultation, including preparation of slides from

D0485 Not a covered benefit None
biopsy material supplied by referring source

Laboratory accession of transepithelial cytologic

D0486 sample, microscopic examination, preparation and Not a covered benefit None
transmission of written report

D0502 Other oral pathology procedures, by report Not a covered benefit None

Non-ionizing diagnostic procedure capable of

D0600 quantifying, monitoring, and recording changes in Not a covered benefit None
structure of enamel, dentin, and cementum

Caries risk assessment and documentation, with a

D0601 Not a covered benefit None
finding of low risk

Caries risk assessment and documentation, with a

D0602 Not a covered benefit None
finding of moderate risk

Caries risk assessment and documentation, with a

D0603 Not a covered benefit None
finding of high risk

antigen testing for a public health related pathogen

D0604 Not a covered benefit None
including coronavirus
antibody testing for a public health related pathogen,
D0605 Not a covered benefit None
including coronavirus
D0701 panoramic radiographic image – image capture only Not a covered benefit None
2-D cephalometric radiographic image – image
D0702 Not a covered benefit None
capture only

10
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

2-D oral/facial photographic image obtained intra-

D0703 Not a covered benefit None
orally or extra-orally – image capture only
D0704 3-D photographic image – image capture only Not a covered benefit None
extra-oral posterior dental radiographic image –
D0705 Not a covered benefit None
image capture only
intraoral – occlusal radiographic image – image
D0706 Not a covered benefit None
capture only
intraoral – periapical radiographic image – image
D0707 Not a covered benefit None
capture only
intraoral – bitewing radiographic image – image
D0708 Not a covered benefit None
capture only
intraoral – complete series of radiographic images –
D0709 Not a covered benefit None
image capture only
D0999 Unspecified diagnostic procedure, by report Not a covered benefit None

11
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
Preventive Services

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

DENTAL PROPHYLAXIS
D1110 Prophylaxis – adult age 14+ Twice per calendar year None
Prophylaxis – child through age 13 (up to 14th
D1120 Twice per calendar year None
birthday)
TOPICAL FLUORIDE TREATMENT OFFICE PROCEDURE
Twice per calendar year through age 18.
D1206 Topical application of fluoride varnish None
Benefit will be in place of D1203, D1204.
D1208 Topical application of fluoride – excluding varnish Twice per calendar year through age 18 None
OTHER PREVENTIVE SERVICES
D1310 Nutritional counseling for control of dental disease Not a covered benefit None
Tobacco counseling for control and prevention of oral
D1320 Covered through age 18 None
disease
counseling for the control and prevention of adverse
D1321 oral, behavioral, and systemic health effects Not a covered benefit None
associated with high-risk substance use
D1330 Oral hygiene instructions Not a covered benefit None
Once in 3 years for dependents through
D1351 Sealant – per tooth age 15 on permanent firstand second Tooth identification
molars
Preventive resin restoration in a moderate to high
D1352 Once in 3 years for permanent teeth only Tooth identification
cariesrisk patient; permanent tooth
D1353 Sealant repair-per tooth Once in 3 years for permanent teeth only Tooth identification
Application of caries arresting medicament – per
D1354 Not a covered benefit None
tooth
D1355 caries preventive medicament application – per tooth Not a covered benefit None

12
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

SPACE MAINTENANCE (PASSIVE APPLIANCES): Designed to prevent tooth movement

Dependents through the age of 18 for
premature loss of primary molars and
D1510 Space maintainer – fixed, unilateral – per quadrant Per Quadrant
permanent first molars, or those that have
not/will not develop
Dependents through the age of 18 for
premature loss of primary molars and
D1516 Space maintainer – fixed – bilateral, maxillary Tooth identification
permanent first molars, or those that have
not/will not develop
Dependents through the age of 18 for
premature loss of primary molars and
D1517 Space maintainer – fixed – bilateral, mandibular Tooth identification
permanent first molars, or those that have
not/will not develop
D1520 Space maintainer – removable – bilateral Not a covered benefit Tooth identification
D1526 Space maintainer – removable – bilateral, maxillary Not a covered benefit Tooth identification
D1527 Space maintainer – removable – bilateral, mandibular Not a covered benefit Tooth identification
Re-cement or re-bond bilateral space maintainer – Once in a 6-month period, but not within
D1551 Arch identification
maxillary six months of insertion by same dentist
Re-cement or re-bond bilateral space maintainer – Once in a 6-month period, but not within
D1552 Arch identification
mandibular six months of insertion by same dentist
Re-cement or re-bond unilateral space maintainer – Once in a 6-month period, but not within
D1553 Arch identification
per quadrant six months of insertion by same dentist
Removal of fixed unilateral space maintainer – per
D1556 No limitations Arch identification
quadrant
Removal of fixed bilateral space maintainer –
D1557 No limitations Arch identification
maxillary
Removal of fixed bilateral space maintainer –
D1558 No limitations Arch identification
mandibular

13
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Dependents through the age of 18 for

premature loss of primary molars and
D1575 Distal shoe space maintainer-fixed-unilateral Tooth identification
permanent first molars, or those that have
not/will not develop

D1999 Unspecified preventative procedure, by report Not a covered benefit None

Restorative Services

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

AMALGAM RESTORATIONS (INCLUDING POLISHING): Amalgam restorations include tooth preparation, localized tissue removal, base, direct and
indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases) Included as part of the restoration. If used,
pins should be reported separately (see D2951). Restorations only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not
covered benefits.

One restoration per surface per tooth per Tooth identification, Surface
D2140 Amalgam – 1 surface, permanent or primary
12 month period identification

One restoration per surface per tooth per Tooth identification, Surface
D2150 Amalgam – 2 surfaces, permanent or primary
12 month period identification

One restoration per surface per tooth per Tooth identification, Surface
D2160 Amalgam – 3 surfaces, permanent or primary 12 month period identification

14
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One restoration per surface per tooth per Tooth identification, Surface
D2161 Amalgam – 4 or more surfaces, permanent or primary
12 month period identification

RESIN-BASED COMPOSITE RESTORATIONS: Resin refers to a broad category of materials including, but not limited to, composites. May include
bonded composite, light-cured composite, etc. Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the
restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass
ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations
are only allowed for fracture or decay. Restorations for erosion, attrition or abrasion are not covered benefits.

One restoration per surface per tooth per Tooth identification, Surface
D2330 Resin-based composite, 1 surface, anterior
12 month period identification

One restoration per surface per tooth per Tooth identification, Surface
D2331 Resin-based composite, 2 surfaces, anterior
12 month period identification

One restoration per surface per tooth per Tooth identification, Surface
D2332 Resin-based composite, 3 surfaces, anterior
12 month period identification

Resin-based composite, 4 or more surfaces or One restoration per surface per tooth per Tooth identification, Surface
D2335
involving incisal angle, anterior 12 month period identification

One per tooth per lifetime; primary teeth

D2390 Resin-based composite crown, anterior Tooth identification
only
One restoration per surface per tooth per
Resin-based composite, 1 surface, posterior, 12 months. Alternate benefit of Tooth identification, Surface
D2391
permanent or primary comparable amalgam restoration. No identification
alternate code for anterior teeth.

15
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One restoration per surface per tooth per

Resin-based composite, 2 surfaces, posterior, 12 months. Alternate benefit of Tooth identification, Surface
D2392
permanent, or primary comparable amalgam restoration. No identification
alternate code for anterior teeth.

One restoration per surface per tooth per

Resin-based composite, 3 surface, posterior, 12 months. Alternate benefit of Tooth identification, Surface
D2393
permanent, or primary comparable amalgam restoration. No identification
alternate code for anterior teeth.

One restoration per surface per tooth per

Resin-based composite, 4 or more surfaces, posterior 12 months. Alternate benefit of Tooth identification, Surface
D2394
permanent, or primary comparable amalgam restoration. No identification
alternate code for anterior teeth.
GOLD FOIL RESTORATIONS

Tooth identification, Surface

D2410 Gold foil, 1 surface Not a covered benefit
identification

Tooth identification, Surface

D2420 Gold foil, 2 surfaces Not a covered benefit
identification

Tooth identification, Surface

D2430 Gold foil, 3 surfaces Not a covered benefit
identification

INLAY/ONLAY RESTORATIONS: inlay – an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does
not restore any cusp tips; onlay – a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces,
but not the entire external surface.

One per tooth per 5 years. Alternate

Tooth identification, Surface
D2510 Inlay – metallic, 1 surfaces (D2140) benefit of comparable amalgam
identification
restoration.

16
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One per tooth per 5 years. Alternate

Tooth identification, Surface
D2520 Inlay – metallic, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.

One per tooth per 5 years. Alternate

Tooth identification, Surface
benefit of comparable amalgam
D2530 Inlay – metallic, 3 or more surfaces (D2160) identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2542 Onlay – metallic, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2543 Onlay – metallic, 3 surfaces (D2160) benefit of comparable amalgam
identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2544 Onlay – metallic, 4 or more surfaces (D2161) benefit of comparable amalgam
identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2610 Inlay – porcelain/ceramic, 1 surface (D2140) benefit of comparable amalgam
identification
restoration.

One per tooth per 5 years. Alternate

Tooth identification, Surface
D2620 Inlay – porcelain/ceramic, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.

One per tooth per 5 years. Alternate

Tooth identification, Surface
D2630 Inlay – porcelain/ceramic, 3 or more surfaces (D2160) benefit of comparable amalgam
identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2642 Onlay – porcelain/ceramic, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.

17
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Tooth identification, Surface

D2643 Onlay – porcelain/ceramic, 3 surfaces One per tooth per 5 years
identification

Tooth identification, Surface

D2644 Onlay – porcelain/ceramic, 4 or more surfaces One per tooth per 5 years
identification

One per tooth per 5 years. Alternate

Tooth identification, Surface
benefit of comparable amalgam
D2650 Inlay – resin-based composite, 1 surface (D2140) identification
restoration.

One per tooth per 5 years. Alternate

Tooth identification, Surface
D2651 Inlay – resin-based composite, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.
One per tooth per 5 years. Alternate
Inlay – resin-based composite, 3 or more surfaces Tooth identification, Surface
D2652 benefit of comparable amalgam
(D2160) identification
restoration.
One per tooth per 5 years. Alternate
Tooth identification, Surface
D2662 Onlay – resin-based composite, 2 surfaces (D2150) benefit of comparable amalgam
identification
restoration.

Tooth identification, Surface

D2663 Onlay – resin-based composite, 3 surfaces One per tooth per 5 years
identification

Tooth identification, Surface

D2664 Onlay – resin-based composite, 4 or more surfaces One per tooth per 5 years
identification

18
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

CROWNS, SINGLE RESTORATIONS ONLY: Crowns are covered to restore fractured or severely diseased teeth when teeth cannot be properly
restored with amalgam or resin restorations. They are non-covered for cosmetic purposes or for replacement of veneers regardless if decayed or
fractured, since services performed in association with a non-covered service are also non-covered. Crowns to correct congenital or developmental
abnormalities are not covered. Submit service for payment with the completion (permanent cementation) date. A gingivectomy performed in conjunction
with a crown should be considered part of the overall procedure and cannot be billed separately.
D2710 Crown – resin-based composite (indirect) Not a covered benefit Tooth identification

Crown - ¾ resin-based composite (indirect), does not

D2712 Not a covered benefit Tooth identification
include facial veneers

D2720 Crown – resin with high-noble metal Not a covered benefit Tooth identification
D2721 Crown – resin with predominantly base metal Not a covered benefit Tooth identification
D2722 Crown – resin with noble metal Not a covered benefit Tooth identification
One in 5 years. Not covered for patients
D2740 Crown – porcelain/ceramic substrate Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2750 Crown – porcelain fused to high-noble metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2751 Crown – porcelain fused to predominantly base metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2752 Crown – porcelain fused to noble metal Tooth identification
under age 14.
Crown - porcelain fused to titanium and titanium One in 5 years. Not covered for patients
D2753 Tooth identification
alloys under age 14.
One in 5 years. Not covered for patients
D2780 Crown – ¾ cast high noble metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2781 Crown – ¾ cast predominantly base metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2782 Crown – ¾ cast noble metal Tooth identification
under age 14.

19
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in 5 years. Not covered for patients

D2783 Crown – ¾ porcelain/ceramic (not veneers) Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2790 Crown – full cast high-noble metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2791 Crown – full-cast predominantly base metal Tooth identification
under age 14.
One in 5 years. Not covered for patients
D2792 Crown – full-cast noble metal Tooth identification
under age 14.
D2794 Crown – titanium Not a covered benefit Tooth identification

Interim crown – further treatment or completion of

D2799 Not a covered benefit Tooth identification
diagnosis necessary prior to final impression

OTHER RESTORATIVE SERVICES

Re-cement or re-bond inlay, onlay, veneer, or partial One in six month period, but not within six
D2910 Tooth identification
coverage restoration months of insertion by same dentist

Re-cement or re-bond indirectly fabricated or

D2915 Not a covered benefit Tooth identification
prefabricated post and core

One in six month period, but not within six

D2920 Re-cement or re-bondcrown Tooth identification
months of insertion by same dentist

D2921 Reattachment of tooth fragment, incisal edge or cusp. Not a covered benefit Tooth identification

D2928 prefabricated porcelain/ceramic crown – permanent Not a covered benefit Tooth identification
tooth
Prefabricated porcelain/ceramic crown – primary One per tooth per lifetime; under age 14;
D2929 Tooth identification
tooth alternate code D2930

20
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D2930 Prefabricated stainless steel crown – primary tooth One per tooth per lifetime; under age 14 Tooth identification
D2931 Prefabricated stainless steel crown – permanent tooth One per tooth per lifetime; under age 14 Tooth identification

One per tooth per lifetime; under age 14;

D2932 Prefabricated resin crown Tooth identification
alternate code D2930

Prefabricated stainless steel crown with resin window One per tooth per lifetime; under age 14;
D2933 Tooth identification
(D2930) alternate code D2931

Prefabricated esthetic coated stainless steel crown – One per tooth per lifetime; under age 14;
D2934 Tooth identification
primary tooth (D2930) alternate code D2932

D2940 Protective restoration Not a covered benefit Tooth identification

D2941 Interim therapeutic restoration – primary dentition Not a covered benefit None
D2949 Restorative foundation for an indirect restoration Not a covered benefit None
D2950 Core build-up, including any pins when required One per tooth per 5 years Tooth identification

No limitations, per tooth. Not covered if

D2951 Pin retention – per tooth, in addition to restoration Tooth identification
submitted with D2950.

Post and core in addition to crown; indirectly

D2952 One per 5 years; alternate code D2954 Tooth identification
fabricated (D2954)

Each additional cast post – same tooth; indirectly

D2953 Not a covered benefit Tooth identification
fabricated

D2954 Prefabricated post and core in addition to crown One per tooth per 5 years Tooth identification

21
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D2955 Post removal Not a covered benefit Tooth identification

D2957 Each additional prefabricated post – same tooth Not a covered benefit Tooth identification
D2960 Labial veneer (resin laminate) – chair side Not a covered benefit Tooth identification
D2961 Labial veneer (resin laminate) – laboratory Not a covered benefit Tooth identification
One in 5 years. Not covered for patients
D2962 Labial veneer (porcelain laminate) – laboratory Tooth identification
under age 14.

Additional procedures to construct new crown under

D2971 Not a covered benefit Tooth identification
existing partial denture framework

D2975 Coping Not a covered benefit Tooth identification

Crown repair, necessary by restorative material
D2980 No limitations Tooth identification
failure
Inlay repair necessitated by restorative material
D2981 No limitations Tooth identification
failure
D2982 Only repair necessitated by restorative material failure No limitations Tooth identification
Veneer repair necessitated by restorative material
D2983 No limitations Tooth identification
failure
D2990 Resin infiltration of incipient smooth surface lesions Not a covered benefit Tooth identification
D2999 Unspecified restorative procedure, by report Not a covered benefit Tooth identification

22
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
Endodontic Services
Please note the following:
• Endodontic procedures include exams, pulp tests, pulpotomy, pulpectomy, extirpation of pulp, pre-operative, operative and post-operative radiographs,
filling of canals, bacteriologic cultures and local anesthesia.
• Endodontic therapy performed specifically for coping or overdenture is not covered.
• Please bill claims for multiple-stage procedures only on the date of completion/insertion.
• Payment for endodontic services does not mean that benefits will be available for subsequent restorative services. Coverage for those services is still
subject to exclusions listed under major restorative guidelines.

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

PULP CAPPING

D3110 Pulp cap direct (excluding final restoration) Not a covered benefit Tooth identification

D3120 Pulp cap indirect (excluding final restoration) Not a covered benefit Tooth identification

PULPOTOMY: Therapeutic pulpotomy (excluding final restoration)

Therapeutic pulpotomy (excluding final restoration) – Pulpotomies considered integral in
removal of pulp coronal to dentinocemental junction conjunction with root canal therapy
D3220 Tooth identification
and application of medicament (not to be used for D3310-D3330 by the same dentist within
apexogenesis) 45 days prior to RCT completion date.
Pulpal debridement reported on the same
Pulpal debridement, primary and permanent teeth not date of service, same provider as root
D3221 Tooth identification
to be used for apexogenesis canal or palliative treatment will deny as
integral or offset

Partial pulpotomy for apexogenesis – permanent

D3222 Not a covered benefit Tooth identification
tooth with incomplete root development

23
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

ENDODONTIC THERAPY ON PRIMARY TEETH

Root canal treatment (D3230, D3240,

D3310, D3320, D3330) reported for the
same tooth number and date of service
Pulpal therapy (resorbable filling) anterior, primary
D3230 within 12 months following pulpal Tooth identification
tooth (excluding final restoration)
regeneration (D3354), will be offset by the
pulpal regeneration (D3354) allowed
amount

Root canal treatment (D3230, D3240,

D3310, D3320, D3330) reported for the
same tooth number and date of service
Pulpal therapy (resorbable filling) posterior primary
D3240 within 12 months following pulpal Tooth identification
tooth (excluding final restoration)
regeneration (D3354), will be offset by the
pulpal regeneration (D3354) allowed
amount

ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow up care)
D3310 Anterior tooth (excluding final restoration) One per tooth per lifetime Tooth identification
D3320 Bicuspid tooth (excluding final restoration) One per tooth per lifetime Tooth identification
D3330 Molar tooth (excluding final restoration) One per tooth per lifetime Tooth identification
Treatment of root canal obstruction; non-surgical
D3331 access in lieu of surgery. Root canal blocked by Not a covered benefit Tooth identification
foreign bodies or calcification of 50% or more of root.
Incomplete endodontic therapy; inoperable, By report, up to 40% of comparable
D3332 Tooth identification
unrestorable, or fractured tooth endodontic procedure fee allowance
D3333 Internal root repair of perforation defects Not a covered benefit Tooth identification
ENDODONTIC RETREATMENT
Retreatment of previous root canal therapy, anterior, Allowed if greater than 3 years since initial
D3346 Tooth identification
by report root canal therapy
24
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Retreatment of previous root canal therapy, bicuspid, Allowed if greater than 3 years since initial
D3347 Tooth identification
by report root canal therapy
Retreatment of previous root canal therapy, molar, by Allowed if greater than 3 years since initial
D3348 Tooth identification
report root canal therapy
APEXIFICATION/RECALCIFICATION AND PULPAL REGENERATION PROCEDURES
Apexification/recalcification: initial visit (apical closure/ No limitation. The final apexification visit
D3351 Tooth identification
calcific repair of perforations, root resorption, etc.) includes root canal therapy.
Apexification/recalcification: interim medication No limitation. The final apexification visit
D3352 Tooth identification
replacement includes root canal therapy.
Apexification/recalcification: final visit (includes
No limitation. The final apexification visit
D3353 completed root canal therapy – apical closure/calcific Tooth identification
includes root canal therapy.
repair of perforations, root resorption, etc.)
PULPAL REGENERATION
D3355 Pulpal regeneration – initial visit No limitation Tooth identification
No limitation. The final apexification visit
D3356 Pulpal regeneration – interim medication replacement Tooth identification
includes root canal therapy.
No limitation. The final apexification visit
D3357 Pulpal regeneration – completion of treatment Tooth identification
includes root canal therapy.
APICOECTOMY/PERIRADICULAR SERVICES: Includes all pre-operative radiographs, bacteriologic cultures, local anesthesia and routine follow-up
care
No Limitation. Not payable within 30 days
D3410 Apicoectomy - anterior Tooth identification
post root canal treatment.
No Limitation. Not payable within 30 days
D3421 Apicoectomy – bicuspid (first root) Tooth identification
post root canal treatment.
No Limitation. Not payable within 30 days
D3425 Apicoectomy – molar (first root) Tooth identification
post root canal treatment.
No Limitation. Not payable within 30 days
D3426 Apicoectomy – (each additional root) Tooth and root identification
post root canal treatment.

25
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Bone graft in conjunction with periradicular surgery –

D3428 Not a covered benefit None
per tooth, single site.
Bone graft in conjunction with periradicular surgery –
D3429 each additional contiguous tooth in the same surgical Not a covered benefit None
site
One per tooth root per lifetime. Only
D3430 Retrograde filling – per root covered when reported with D3410, Tooth and root identification
D3421, D3425, and D3426.
Biologic materials to aid in soft and osseous tissue
D3431 Not a covered benefit None
regeneration in conjunction with periradicular surgery
Guided tissue regeneration, resorbable barrier, per
D3432 Not a covered benefit None
site, in conjunction with periradicular surgery
One per tooth per lifetime for multi-rooted
D3450 Root amputation – per root Tooth identification
posterior teeth
D3460 Endodontic endosseous implant Not a covered benefit Tooth identification
Intentional reimplantation (including necessary
D3470 Not a covered benefit Tooth identification
splinting)
Basic - once per tooth per lifetime. Denied
as integral if reported with an apiocetomy
D3471 surgical repair of root resorption – anterior by the sane dentist on the same date or Tooth identification
any time after. Eligible for review on
appeal
Basic - once per tooth per lifetime. Denied
as integral if reported with an apiocetomy
D3472 surgical repair of root resorption – premolar by the sane dentist on the same date or Tooth identification
any time after. Eligible for review on
appeal
Basic - once per tooth per lifetime. Denied
as integral if reported with an apiocetomy
D3473 surgical repair of root resorption – molar by the sane dentist on the same date or Tooth identification
any time after. Eligible for review on
appeal

26
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Basic - once per tooth per lifetime. Denied

as integral if reported with an apiocetomy
surgical exposure of root surface without apicoectomy
D3501 by the sane dentist on the same date or Tooth identification
or repair of root resorption – anterior
any time after. Eligible for review on
appeal
Basic - once per tooth per lifetime. Denied
as integral if reported with an apiocetomy
surgical exposure of root surface without apicoectomy
D3502 by the sane dentist on the same date or Tooth identification
or repair of root resorption – premolar
any time after. Eligible for review on
appeal
Basic - once per tooth per lifetime. Denied
as integral if reported with an apiocetomy
surgical exposure of root surface without apicoectomy
D3503 by the sane dentist on the same date or Tooth identification
or repair of root resorption – molar
any time after. Eligible for review on
appeal
OTHER ENDODONTIC PROCEDURES
Surgical procedure for isolation of tooth with rubber
D3910 Not a covered benefit None
dam
D3911 Intraorifice barrier Not a covered benefit None

Hemisection (including any root removal), not

D3920 One per tooth per lifetime Tooth identification
including root canal therapy

One per tooth per lifetime, eligiblefor

D3921 Decoronation or submergence of an erupted tooth Tooth identification
GA/IV sedation

Canal preparation and fitting of preformed dowel or

D3950 One per tooth per lifetime Tooth identification
post

27
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Tooth identification, Detailed

narrative, Current dated pre-
D3999 Unspecified endodontic procedure, by report Not a covered benefit
and post-operative periapical
radiographs

Periodontal Services
Procedure Billing Guidelines
• A quadrant is defined as four or more contiguous teeth in a quadrant. A partial quadrant is defined as one to three teeth in a quadrant.
• For billing purposes, a sextant is not a recognized designation by the American Dental Association.
• To be covered, alveolar crestal bone loss must be evident radiographically for scaling and root planing-.
• When more than one periodontal service (codes D4000-D4999) is completed within the same site or quadrant on the same date of service, Arkansas Blue
Cross will pay for the more extensive treatment as payment for the total service.
• Benefits for all periodontal services are limited to two quadrants per date of service. If you wish to request an exception due to a medical condition that
may require your patient to receive extended treatment, please include a detailed narrative including general or intravenous anesthesia record, medical
condition and length of appointment time for consideration.

Payment for Surgical Services

• Payment for definitive periodontal service includes follow-up evaluation for both surgical and non-surgical procedures.
• No more than two quadrants of surgical or non-surgical services may be covered when done on the same date of service. To request an exception due to
a medical condition that may require your patient to receive extended periodontal treatment, please submit a detailed narrative including general or
intravenous anesthesia record, medical condition and length of appointment time for consideration with the claim form.
• When localized procedures are performed in the same quadrant within 36 months, the payment will not exceed the full quadrant allowance.
• Periodontal services are benefits when performed for the treatment of periodontal disease around natural teeth. There are no benefits for these
procedures when billed in conjunction with or in preparation for implants, ridge augmentation, extractions sites and endodontic surgeries.
• When localized surgical or pre-surgical services are performed in the same quadrants within coverage time guidelines, payment for the services will not
exceed the full quadrant allowance.

28
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

SURGICAL SERVICES (INCLUDING USUAL POST-OPERATIVE SERVICES)

Gingivectomy or gingivoplasty – 4 or more contiguous One per quadrant in 36 months, minimum
D4210 Quadrant identification
teeth or tooth-bounded spaces per quadrant age 19
Gingivectomy or gingivoplasty – 1 to 3 contiguous One per quadrant in 36 months, minimum
D4211 Tooth identification
teeth or tooth bounded spaces per quadrant age 19
Gingivectomy or gingivoplasty to allow access for One per quadrant in 36 months, minimum
D4212 Tooth identification
restorative procedure, per tooth age 19
Anatomical crown exposure – 4 or more contiguous
D4230 Not a covered benefit Quadrant identification
teeth or tooth bounded spaces per quadrant
Anatomical crown exposure – 1 to 3 teeth or tooth
D4231 Not a covered benefit Tooth identification
bounded spaces per quadrant

Gingival flap procedure, including root planing – 4 or

One per quadrant in 36 months, minimum
D4240 more contiguous teeth or tooth-bounded spaces per Quadrant identification
age 19
quadrant

Gingival flap procedure - 1 to 3 contiguous teeth or One per quadrant in 36 months, minimum
D4241 Tooth identification
tooth bounded spaces per quadrant age 19

D4245 Apically repositioned flap Not a covered benefit Quadrant identification

D4249 Clinical crown lengthening hard tissue One per tooth per lifetime, by report Tooth identification

One per quadrant in 36 months, min age

Osseous surgery (including flap and closure) – four or
19. If performed on same day as crown
D4260 more contiguous teeth or tooth-bounded spaces per Quadrant identification
lengthening, osseous surgery will not be
quadrant
covered.

One in 36 months, minimum age 19 If

Osseous surgery, one to three contiguous teeth or performed on same day as crown
D4261 Tooth identification
tooth bounded spaces per quadrant lengthening, osseous surgery will not be
covered
29
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D4263 Bone replacement graft – first site in quadrant No limitations Tooth identification
Bone replacement graft – each additional site in
D4264 No limitations Tooth identification
quadrant

Biologic materials to aid in soft and osseous tissue

D4265 Not a covered benefit Tooth identification
regeneration, per site

Guided tissue regeneration resorbable barrier, per One per 36 months. Dental Advisor review
D4266 Tooth identification
site is required.
Guided tissue regeneration non-restorable barrier, per One per 36 months. Dental Advisor review
D4267 Tooth identification
site (includes membrane removal) is required.
D4268 Surgical revision procedure, per tooth One per tooth per lifetime Tooth identification
D4270 Pedicle soft tissue graft procedure One in 36 months, minimum age 19 Tooth identification
Autogenous connective tissue graft procedure,
D4273 (including donor and recipient surgical sites) first One in 36 months, minimum age 19 Tooth identification
tooth, implant, or edentulous tooth position in graft
Distal or proximal wedge procedure (when not
Tooth identification Quadrant
D4274 performed in conjunction with surgical procedures on Not a covered benefit
identification
the same anatomical area)
Non-autogenous connective tissue graft (including One in 36 months, minimum age 19.
D4275 recipient site and donor material) first tooth, implant, Alternate benefit of comparable free soft Tooth identification
or edentulous tooth position in graft tissue graft procedure.
One in 36 months, minimum age 19.
Combined connective tissue and pedicle graft, per
D4276 Alternate benefit of comparable free soft Tooth identification
tooth
tissue graft procedure.
Free soft tissue graft procedure (including recipient
D4277 and donor surgical site), first tooth, implant, or One in 36 months, minimum age 19 Tooth or site identification
edentulous tooth position in graft

30
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Free soft tissue graft procedure (including recipient

and donor surgical sites), each additional contiguous
D4278 One in 36 months, minimum age 19 Tooth or site identification
tooth, implant, or edentulous tooth position in same
graft site
Autogenous connective tissue graft procedure
Payment limited to three teeth per site. All
(including donor and recipient surgical sites) – each
D4283 other limitations and policies for soft tissue Tooth identification
additional contiguous tooth, implant or edentulous
graft apply.
tooth position in same graft site
Non-autogenous connective tissue graft procedure
Payment limited to three teeth per site. All
(including recipient surgical site and donor material) –
D4285 other limitations and policies for soft tissue Tooth identification
each additional contiguous tooth, implant, or
graft apply
edentulous tooth position in same graft site

NON-SURGICAL PERIODONTAL SERVICES

Splint – intra-coronal; natural teeth or prosthetic
Not a covered benefit None
D4322 crowns

Splint – extra-coronal; natural teeth or prosthetic

Not a covered benefit None
D4323 crowns

One per quadrant in 24 months, minimum

Periodontal scaling and root planing, 4 or more teeth age 19, D1110 not payable if billed on
D4341 Quadrant identification
per quadrant same day. Limited to two quadrants per
visit.
One per quadrant in 24 months, minimum
Periodontal scaling and root planing, 1 - 3 teeth per
D4342 age 19, D1110 not payable if billed on Tooth identification
quadrant
same day.
Scaling in presence of generalized moderate or
D4346 severe gingival inflammation – full mouth, after Once per 24 months None
evaluation

31
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Full mouth debridement to enable a comprehensive Covered once in a calendar year, no age
D4355 None
oral evaluation and diagnosis on a subsequent visit limits

Localized delivery of antimicrobial agents via a

controlledrelease vehicle into diseased crevicular
D4381 Not a covered benefit Tooth identification
tissue, per tooth, by report (only to be used as a site
specific adjunct to localized disease)
OTHER PERIODONTAL SERVICES
Four per calendar year or two routine
Periodontal maintenance procedures (following active cleanings (D1110, D1120) and two perio
D4910 None
therapy) maintenance visits per calendar year
following active periodontal therapy.
Unscheduled dressing change (performed by other
D4920 Not a covered benefit None
than treating dentist or their staff)

Not a covered benefit; Integral to any

D4921 Gingival irrigation – per quadrant None
perio service.

D4999 Unspecified periodontal procedure, by report Not a covered benefit None

32
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
Prosthodontics, Removable
Please bill claims for multiple-stage procedures on the date of completion/insertion. Services may be non-covered for the following conditions:
• Untreated bone loss: An abutment tooth has poor-to-hopeless prognosis from either a restorative or periodontal perspective
• Periapical pathology or unresolved, incomplete, or failed endodontic therapy
• Treatment of TMJ to increase vertical dimension or restore occlusion

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

COMPLETE DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)

D5110 Complete denture – maxillary One in 5 years None

D5120 Complete denture – mandibular One in 5 years None

D5130 Immediate denture – maxillary One in 5 years None

D5140 Immediate denture – mandibular One in 5 years None

PARTIAL DENTURES: For the following codes, denture base presumed to include any conventional clasps, rests,
and teeth

Maxillary partial denture – resin base (including

D5211 One in 5 years Tooth identification
retentive/clasping materials, rests, and teeth)

Mandibular partial denture – resin base (including

D5212 One in 5 years Tooth identification
retentive/clasping materials, rests, and teeth)

Maxillary partial denture – cast metal framework with

D5213 One in 5 years Tooth identification
resin denture bases

Mandibular partial denture – cast metal framework

D5214 One in 5 years Tooth identification
with resin denture bases

33
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Immediate maxillary partial denture – resin base

D5221 One in 5 years Tooth identification
(including any conventional clasps, rests and teeth)

Immediate mandibular partial denture – resin base

D5222 One in 5 years Tooth identification
(including any conventional clasps, rests and teeth)

Immediate maxillary partial denture – cast metal

D5223 framework with resin denture bases (including any One in 5 years Tooth identification
conventional clasps, rests, and teeth)

Immediate mandibular partial denture – cast metal

D5224 framework with resin denture bases (including any One in 5 years Tooth identification
conventional clasps, rests and teeth)

D5225 Maxillary partial denture - flexible base One in 5 years Tooth identification

D5226 Mandibular partial denture - flexible base One in 5 years Tooth identification

Immediate maxillary partial denture - flexible base

D5227 One in 5 years Tooth identification
(including any clasps, rests and teeth)

Immediate mandibular partial denture - flexible base

D5228 One in 5 years Tooth identification
(including any clasps, rests and teeth)

Removable unilateral partial denture – one piece cast

D5282 One in 5 years Tooth identification
metal (including clasps and teeth), maxillary

34
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Removable unilateral partial denture – one piece cast

D5283 One in 5 years Tooth identification
metal (including clasps and teeth), mandibular

Removable unilateral partial denture – one piece

D5284 flexible base (including clasps and teeth) – per One in 5 years. Minimum age 14. Quadrant identification
quadrant

Removable unilateral partial denture – one piece resin

D5286 One in 5 years. Minimum age 14. Quadrant identification
(including clasps and teeth) – per quadrant

No limitations. Considered integral if

D5410 Adjust complete denture – maxillary None
performed within 6 months of insertion.

No limitations. Considered integral if

D5411 Adjust complete denture – mandibular None
performed within 6 months of insertion.

No limitations. Considered integral if

D5421 Adjust partial denture – maxillary None
performed within 6 months of insertion.

35
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

No limitations. Considered integral if

D5422 Adjust partial denture – mandibular None
performed within 6 months of insertion.

REPAIRS TO COMPLETE AND PARTIAL DENTURES

D5511 Repair broken complete denture base, mandibular No limitations Arch identification

D5512 Repair broken complete denture base, maxillary No limitations Arch identification

Replace missing or broken teeth (complete denture),

D5520 No limitations Tooth identification
each tooth

D5611 Repair resin partial denture base, mandibular No limitations Arch identification

D5612 Repair resin partial denture base, maxillary No limitations Arch identification

D5621 Repair cast partial framework, mandibular No limitations Arch identification

D5622 Repair cast partial framework, maxillary No limitations Arch identifcation

Repair or replace broken retentive/clasping materials

D5630 No limitations None
per tooth

36
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D5640 Repair broken teeth – per tooth No limitations Tooth identification

D5650 Add tooth to existing partial denture No limitations Tooth identification

D5660 Add clasp to existing partial denture – per tooth No limitations Tooth identification

Replace all teeth and acrylic on cast metal framework

D5670 No limitations None
– maxillary

Replace all teeth and acrylic on cast metal framework

D5671 No limitations None
– mandibular

DENTURE REBASE PROCEDURES: process of refitting a denture by replacing the base material

One in a 3 year period. Considered

D5710 Rebase complete maxillary denture integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5711 Rebase complete mandibular denture integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5720 Rebase maxillary partial denture integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5721 Rebase mandibular partial denture integral if performed within 6 months of None
insertion.

37
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 3 year period. Considered

D5725 Rebase hybrid prosthesis integral if performed within 6 months of None
insertion.

DENTURE RELINE PROCEDURES: The process of resurfacing the tissue side of a denture with new base material

One in a 3 year period. Considered

D5730 Reline complete maxillary denture (chair side) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5731 Reline complete mandibular denture (chair side) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5740 Reline maxillary partial denture (chair side) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5741 Reline mandibular partial denture (chair side) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5750 Reline complete maxillary denture (laboratory) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5751 Reline complete mandibular denture (laboratory) integral if performed within 6 months of None
insertion.
One in a 3 year period. Considered
D5760 Reline upper maxillary denture (laboratory) integral if performed within 6 months of None
insertion.

38
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 3 year period. Considered

D5761 Reline mandibular partial denture (laboratory) integral if performed within 6 months of None
insertion.

One in a 3 year period. Considered

Soft liner for complete or partial removable denture –
D5765 integral if performed within 6 months of None
indirect
insertion.

OTHER REMOVABLE PROSTHETIC SERVICES

D5810 Interim complete denture (maxillary) Not a covered benefit None

D5811 Interim complete denture (mandibular) Not a covered benefit None

D5820 Interim partial denture (maxillary) Not a covered benefit None

D5821 Interim partial denture (mandibular) Not a covered benefit None

D5850 Tissue conditioning, maxillary Not a covered benefit None

D5851 Tissue conditioning, mandibular Not a covered benefit None

D5862 Precision attachment, by report Not a covered benefit None

1 in a 5 year period; D5110 automatic

D5863 Overdenture – complete maxillary None
alternate benefit

39
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

1 in a 5 year period; D5113 automatic

D5864 Overdenture – partial maxillary None
alternate benefit

1 in a 5 year period; D5120 automatic

D5865 Overdenture – complete mandibular None
alternate benefit

1 in a 5 year period; D5114 automatic

D5866 Overdenture – partial mandibular None
alternate benefit

Replacement of replaceable part or semi-precision or

D5867 Not a covered benefit None
precision attachment (male or female component)

Modification of removable prosthesis following implant

D5875 Not a covered benefit None
surgery

Add metal substructure to acrylic full denture (per

D5876 Not a covered benefit Arch identification
arch)

Unspecified removable prosthodontic procedure, by Tooth identification, Arch

D5899 Not a covered benefit
report identification

MAXILLOFACIAL PROSTHETICS

D5911 Facial moulage (sectional) Not a covered benefit None

D5912 Facial moulage (complete) Not a covered benefit None

D5913 Nasal prosthesis Not a covered benefit None

D5914 Auricula prosthesis Not a covered benefit None

40
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D5915 Orbital prosthesis Not a covered benefit None

D5916 Ocular prosthesis Not a covered benefit None

D5919 Facial prosthesis Not a covered benefit None

D5922 Nasal septal prosthesis Not a covered benefit None

D5923 Ocular prosthesis, interim Not a covered benefit None

D5924 Cranial prosthesis Not a covered benefit None

D5925 Facial augmentation implant prosthesis Not a covered benefit None

D5926 Nasal prosthesis, replacement Not a covered benefit None

D5927 Auricular prosthesis, replacement Not a covered benefit None

D5928 Orbital prosthesis, replacement Not a covered benefit None

D5929 Facial prosthesis, replacement Not a covered benefit None

D5931 Obturator prosthesis, surgical Not a covered benefit None

41
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D5932 Obturator prosthesis, definitive Not a covered benefit None

D5933 Obturator prosthesis, modification Not a covered benefit None

D5934 Mandibular resection prosthesis with flange Not a covered benefit None

D5935 Mandibular resection prosthesis without guide flange Not a covered benefit None

D5936 Obturator prosthesis, interim Not a covered benefit None

D5937 Trismus appliance (not for TMD treatment) Not a covered benefit None

D5951 Feeding aid Not a covered benefit None

D5952 Speech aid prosthesis, pediatric Not a covered benefit None

D5953 Speech aid prosthesis, adult Not a covered benefit None

D5954 Palatal augmentation prosthesis Not a covered benefit None

D5955 Palatal lift prosthesis, definitive Not a covered benefit None

D5958 Palatal lift prosthesis, interim Not a covered benefit None

42
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D5959 Palatal lift prosthesis, modification Not a covered benefit None

D5960 Speech aid prosthesis, modification Not a covered benefit None

D5982 Surgical stent Not a covered benefit None

D5983 Radiation carrier Not a covered benefit None

D5984 Radiation shield Not a covered benefit None

D5985 Radiation cone locator Not a covered benefit None

D5986 Fluoride gel carrier Not a covered benefit None

D5987 Commissure splint Not a covered benefit None

D5988 Surgical splint Not a covered benefit None

D5991 Vesiculobullous disease medicament carrier Not a covered benefit None

D5992 Adjust maxillofacial prosthetic appliance, by report Not a covered benefit None

Maintenance and cleaning of a maxillofacial

D5993 prosthesis (extra or intraoral) other than required Not a covered benefit None
adjustments, by report

43
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

periodontal medicament carrier with peripheral seal –

D5995 Not a covered benefit None
laboratory processed - maxillary

periodontal medicament carrier with peripheral seal –

D5996 Not a covered benefit None
laboratory processed - mandibular

D5999 Unspecified maxillofacial prosthesis, by report Not a covered benefit Detailed narrative

Implant Services
Coverage
General Information
Benefits for single-tooth endosteal dental implants, single-tooth abutments, and single-tooth implant/abutment supported crowns are covered up to the
member’s annual maximum.

Implant Services
Coverage for implant services has a maximum lifetime dollar amount and covers the surgical placement of endosteal implants with a minimum age
qualification of 16 for the replacement of teeth 2-15 and teeth 18-31.
The implant rider does not cover the following services:
• Special preparatory radiographic or imaging studies (i.e., tomographic, CT, or MRI)
• Adjunctive periodontal (D4000 series) or surgical (D7000 series) procedures in preparation for implant placement, in association with implant placement,
or in association with salvage attempts of a failing implant; (covers implants only)
• Maxillofacial prosthetic procedure D5982, surgical stent (implant positioning type); (covers implants only)

Please also note:

• Routine radiographs (i.e., periapical and panoramic) may be covered under the member’s general dental insurance policy to the same extent and under
the same conditions and guidelines as those applied to a natural tooth.
• The frequency limitation for dental implants is once per tooth (replacement) per 60 months.

44
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

IMPLANT SERVICES

Surgical placement of implant body, endosteal One in a 5-year period; not covered for
D6010 Tooth area identification
implant patients under age 16

One in a 5-year period; not covered for

D6011 Second stage implant surgery Tooth identification
patients under age 16
Surgical placement of interim implant body for One in a 5-year period; not covered for
D6012 Tooth identification
transitional prosthesis, endosteal implant patients under age 16
One in a 5-year period; not covered for
D6013 Surgical placement of mini implant. Tooth identification
patients under age 16
One in a 5-year period; not covered for
D6040 Surgical placement, eposteal implant Tooth identification
patients under age 16
One in a 5-year period; not covered for
D6050 Surgical placement, transosteal implant Tooth identification
patients under age 16
D6051 Interim abutment Not a covered benefit None

IMPLANT-SUPPORTED PROSTHETICS

Dental implant connecting bar – implant supported or One in a 5-year period; not covered for
D6055 None
abutment supported patients under age 16

One in a 5-year period; not covered for

D6056 Prefabricated abutment, including placement Tooth identification
patients under age 16
One in a 5-year period; not covered for
D6057 Custom abutment, including placement Tooth identification
patients under age 16
One in a 5-year period; not covered for
D6058 Abutment-supported porcelain/ceramic crown Tooth identification
patients under age 16

Abutment-supported porcelain fused to metal crown One in a 5-year period; not covered for
D6059 Tooth identification
(high noble metal) patients under age 16

45
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Abutment-supported porcelain fused to metal crown One in a 5-year period; not covered for
D6060 Tooth identification
(predominantly base metal) patients under age 16

Abutment-supported porcelain fused to metal crown One in a 5-year period; not covered for
D6061 Tooth identification
(noble metal) patients under age 16

Abutment-supported cast metal crown (high noble One in a 5-year period; not covered for
D6062 Tooth identification
metal) patients under age 16

Abutment-supported cast metal crown (predominantly One in a 5-year period; not covered for
D6063 Tooth identification
base metal) patients under age 16

One in a 5-year period; not covered for

D6064 Abutment-supported cast metal crown (noble metal) Tooth identification
patients under age 16
One in a 5-year period; not covered for
D6065 Implant-supported porcelain/ceramic crown Tooth identification
patients under age 16

Implant-supported porcelain fused to metal crown One in a 5-year period; not covered for
D6066 Tooth identification
(titanium, titanium alloy, high noble metal) patients under age 16

Implant supported metal crown (titanium, titanium One in a 5-year period; not covered for
D6067 Tooth identification
alloy, high noble metal) patients under age 17

One in a 5-year period; not covered for

Abutment supported retainer for porcelain/ceramic
D6068 patients under age 16; excludes third Tooth identification
FPD
molar replacement

46
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for

Abutment-supported retainer for porcelain fused to patients under age 16; excludes third
D6069 metal FPD (high noble metal) molar replacement Tooth identification

One in a 5-year period; not covered for

Abutment-supported retainer for porcelain fused to
D6070 patients under age 16; excludes third Tooth identification
metal FPD (predominately base metal)
molar replacement

One in a 5-year period; not covered for

Abutment-supported retainer for porcelain fused to
D6071 patients under age 16; excludes third Tooth identification
metal FPD (noble metal)
molar replacement

One in a 5-year period; not covered for

Abutment-supported retainer for cast metal FPD (high
D6072 patients under age 16; excludes third Tooth identification
noble metal)
molar replacement

One in a 5-year period; not covered for

Abutment-supported retainer for cast metal FPD
D6073 patients under age 16; excludes third Tooth identification
(predominately base metal)
molar replacement

One in a 5-year period; not covered for

Abutment-supported retainer for cast metal FPD
D6074 patients under age 16; excludes third Tooth identification
(noble metal)
molar replacement

One in a 5-year period; not covered for

D6075 Implant-supported retainer for ceramic FPD patients under age 16; excludes third Tooth identification
molar replacement

Implant-supported retainer for porcelain fused to One in a 5-year period; not covered for
D6076 metal FPD (titanium, titanium alloy, or high noble patients under age 16; excludes third Tooth identification
metal) molar replacement

47
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for

patients under age 16; excludes third
Implant-supported retainer for cast metal FPD
D6077 molar replacement Tooth identification
(titanium, titanium alloy, or high noble metal)
OTHER IMPLANT SERVICES

Implant maintenance procedures when prosthesis are

D6080 removed and reinserted, including cleansing of No limitations None
prosthesis and abutments.

Scaling and debridement in the presence of

inflammation of mucositis of a single implant,
D6081 Not a covered benefit None
including cleaning of the implant surfaces, without flap
entry and closure

One in a 5-year period; not covered for

Implant supported crown – porcelain fused to
D6082 patients under age 16; excludes third Tooth identification
predominantly base alloys
molar replacement

One in a 5-year period; not covered for

Implant supported crown – porcelain fused to noble
D6083 patients under age 16; excludes third Tooth identification
alloys
molar replacement

One in a 5-year period; not covered for

Implant supported crown – porcelain fused to titanium
D6084 patients under age 16; excludes third Tooth identification
and titanium alloys
molar replacement

D6085 Provisional implant crown Not a covered benefit None

48
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for

D6086 Implant supported crown – predominantly base alloys patients under age 16; excludes third Tooth identification
molar replacement

One in a 5-year period; not covered for

patients under age 16; excludes third
D6087 Implant supported crown – noble alloys Tooth identification
molar replacement

One in a 5-year period; not covered for

Implant supported crown – titanium and titanium
D6088 patients under age 16; excludes third Tooth identification
alloys
molar replacement

D6090 Repair implant supported prosthesis, by report No limitations Tooth identification

Replacement of semi-precision or precision

D6091 attachment of implant/abutmentsupported prosthesis, No limitations Tooth identification
per attachment

Re-cement or re-bond implant/abutment-supported One in six month period, but not within six
D6092 Tooth identification
crown months of insertion by same dentist

Re-cement or re-bond implant/abutment-supported One in six month period, but not within six
D6093 Tooth identification
fixed partial denture months of insertion by same dentist

One in a 5-year period; not covered for

D6094 Abutment supported crown, titanium Tooth identification
patients under age 16
D6095 Repair implant abutment, by report Once every six months Tooth identification

49
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D6096 Remove broken implant retaining screw Once every six months Tooth identification

One in a 5-year period; not covered for

Abutment supported crown – porcelain fused to
D6097 patients under age 16; excludes third Tooth identification
titanium and titanium alloys
molar replacement

One in a 5-year period; not covered for

Implant supported retainer – porcelain fused to
patients under age 16; excludes third
D6098 predominantly base alloys Tooth identification
molar replacement

One in a 5-year period; not covered for

Implant supported retainer for FPD – porcelain fused
D6099 patients under age 16; excludes third Tooth identification
to noble alloys
molar replacement

D6100 Implant removal, by report No limitations Tooth identification

Debridement of a peri-implant defect or defects

surrounding a single implant, and surface cleaning of
D6101 Not a covered benefit None
the exposed implant surfaces, including flap entry and
closure

Debridement and osseous contouring of a peri-

implant defect or defects surrounding a single implant
D6102 Not a covered benefit None
and includes surface cleaning of the exposed implant
surfaces, including flat entry and closure

Bone graft for repair of peri-implant defect does not

include flap entry and closure. Placement of a barrier
D6103 Not a covered benefit None
membrane or biologic materials to aid in osseous
regeneration are reported separately.

50
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D6104 Bone graft at time of implant placement Not a covered benefit None

Implant/abutment supported removable denture for One in five year period. Not covered for
D6110 None
edentulous arch-maxillary patients under 16.

Implant/abutment supported removable denture for One in five year period. Not covered for
D6111 None
edentulous arch-mandibular patients under 16.

Implant/abutment supported removable denture for One in five year period. Not covered for
D6112 None
partially edentulous arch-maxillary patients under 16.

Implant/abutment supported removable denture for One in five year period. Not covered for
D6113 None
partially edentulous arch-mandibular patients under 16.

Implant/abutment supported fixed denture for One in five year period. Not covered for
D6114 None
edentulous arch-maxillary patients under 16.

Implant/abutment supported fixed denture for One in five year period. Not covered for
D6115 None
edentulous arch-mandibular patients under 16.

Implant/abutment supported fixed denture for partially One in five year period. Not covered for
D6116 None
edentulous arch-maxillary patients under 16.

51
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Implant/abutment supported fixed denture for partially One in five year period. Not covered for
D6117 None
edentulous arch-mandibular patients under 16.

Implant/abutment supported interim fixed denture for

D6118 Not a covered benefit None
edentulous arch-mandibular
Implant/abutment supported interim fixed denture for
D6119 Not a covered benefit None
edentulous arch-maxillary

One in a 5-year period; not covered for

Implant supported retainer – porcelain fused to
D6120 patients under age 16; excludes third Tooth identification
titanium and titanium alloys
molar replacement

One in a 5-year period; not covered for

Implant supported retainer for metal FPD –
D6121 patients under age 16; excludes third Tooth identification
predominantly base alloys
molar replacement

One in a 5-year period; not covered for

Implant supported retainer for metal FPD – noble
D6122 patients under age 16; excludes third Tooth identification
alloys
molar replacement

One in a 5-year period; not covered for

Implant supported retainer for metal FPD – titanium
D6123 patients under age 16; excludes third Tooth identification
and titanium alloys
molar replacement

D6190 Radiographic/Surgical implant index, by report Not a covered benefit None

D6191 semi-precision abutment - placement Not a covered benefit None

D6192 semi-precision attachment - placement Not a covered benefit None

52
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for

D6194 Tooth identification
Abutment-supported retainer crown for FPD, titanium patients under age 16.
One in a 5-year period; not covered for
Abutment supported retainer – porcelain fused to
D6195 patients under age 16; excludes third Tooth identification
titanium and titanium alloys
molar replacement
D6198 Remove interim implant component Covered as part of implant rider only Tooth identification
D6199 Unspecified implant procedure, by report Not a covered benefit Tooth identification

Prosthodontics, Fixed
Benefits
• Please bill claims for multiple-stage procedures on the date of completion/insertion of the final restoration.
• Treatments must follow generally accepted dental practice and must be necessary and appropriate for the dental condition. The foundation of
generally accepted dental practice continues to be:
o Establishing periodontal health prior to final phase restoration prosthetic dentistry
o Avoiding incomplete or technically deficient endodontic treatment that is detrimental to the long-term prognosis of the tooth and
subsequent oral health

When Services Are Non-Covered

Fixed prosthodontics will not be covered if these conditions are present:
• Untreated bone loss
• An abutment tooth has poor-to-hopeless prognosis from either a restorative or periodontal perspective
• Periapical pathology or unresolved, incomplete or failed endodontic therapy
• Service meant to treat TMJ, increase vertical dimension or restore occlusion
Submission Requirements:
Description of Service Procedure Guidelines
Participating Providers

FIXED PARTIAL DENTURE PONTICS

One in a 5-year period; not covered for
D6205 Pontic – indirect resin-based composite Tooth identification
patients under age 15

53
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for

D6210 Pontic – cast high noble Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6211 Pontic – cast predominantly base metal Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6212 Pontic – cast noble metal Tooth identification
patients under age 15
D6214 Pontic – titanium Not a covered benefit Tooth identification
One in a 5-year period; not covered for
D6240 Pontic – porcelain fused to high noble metal Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6241 Pontic – porcelain fused to predominantly base metal Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6242 Pontic – porcelain fused to noble metal Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6243 CDT Code Tooth identification
patients under age 15
One in a 5-year period; not covered for
D6245 Pontic – porcelain/ceramic Tooth identification
patients under age 15
D6250 Pontic – resin with high noble metal Not a covered benefit Tooth identification
D6251 Pontic – resin with high noble metal Not a covered benefit Tooth identification
D6252 Pontic – resin with noble metal Not a covered benefit Tooth identification
Interim pontic – further treatment or completion of
D6253 Not a covered benefit Tooth identification
diagnosis necessary prior to final impression
FIXED PARTIAL DENTURE RETAINERS – INLAYS/ONLAYS
Retainer – cast metal for resin-bonded fixed One in a 5-year period; not covered for
D6545 Tooth identification
prosthesis patients under age 15
Retainer – porcelain/ ceramic for resin-bonded fixed One in a 5-year period; not covered for
D6548 Tooth identification
prosthesis patients under age 15
One in a 5-year period; not covered for
D6549 Resin retainer – for resin bonded fixed prosthesis Tooth identification
patients under age 15

54
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

One in a 5-year period; not covered for Tooth identification, Surface

D6600 Retainer Inlay – porcelain/ceramic, 2 surfaces
patients under age 15 identification

Retainer Inlay – porcelain/ceramic, 3 or more One in a 5-year period; not covered for Tooth identification, Surface
D6601
surfaces patients under age 15 identification

One in a 5-year period; not covered for Tooth identification, Surface

D6602 Retainer Inlay – high-noble metal, 2 surfaces
patients under age 15 identification
One in a 5-year period; not covered for Tooth identification, Surface
D6603 Retainer Inlay – high-noble metal, 3 or more surfaces
patients under age 15 identification
Retainer Inlay – cast, predominately base metal, 2 One in a 5-year period; not covered for Tooth identification Pre-
D6604
surfaces patients under age 15 treatment recommended

Retainer Inlay – cast, predominately base metal, 3 or One in a 5-year period; not covered for Tooth identification Pre-
D6605
more surfaces patients under age 16 treatment recommended

One in a 5-year period; not covered for Tooth identification Pre-

D6606 Retainer Inlay – cast noble metal, 2 surfaces
patients under age 17 treatment recommended

One in a 5-year period; not covered for Tooth identification Pre-

D6607 Retainer Inlay – cast noble metal, 3 or more surfaces patients under age 18 treatment recommended

Tooth identification Surface

One in a 5-year period; not covered for
D6608 Retainer Onlay – porcelain ceramic, 2 surface identification must include B or
patients under age 19
L surface

55
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Tooth identification Surface

Retainer Onlay – porcelain ceramic, 3 or more One in a 5-year period; not covered for
D6609 identification must include B or
surfaces patients under age 20
L surface

Tooth identification Surface

One in a 5-year period; not covered for
D6610 Retainer Onlay – cast high noble metal, 2 surface identification must include B or
patients under age 15
L surface

Tooth identification Surface

One in a 5-year period; not covered for
D6611 Retainer Onlay – cast high noble, 3 or more surfaces identification must include B or
patients under age 16
L surface

Tooth identification Surface

Retainer Onlay – cast predominately base metal, 2 One in a 5-year period; not covered for
D6612 identification must include B or
surfaces patients under age 17
L surface

Tooth identification Surface

Retainer Onlay – cast predominately base metal, 3 or One in a 5-year period; not covered for
D6613 identification must include B or
more surfaces patients under age 18
L surface

Tooth identification Surface

One in a 5-year period; not covered for
D6614 Retainer Onlay – cast noble metal, 2 surfaces identification must include B or
patients under age 19
L surface

Tooth identification Surface

Retainer Onlay – cast noble metal, 3 or more One in a 5-year period; not covered for
D6615 identification must include B or
surfaces patients under age 20
L surface

Surface identification must

D6624 Retainer Inlay – titanium Not a covered benefit
include B or L surface

56
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Tooth identification Surface

D6634 Retainer Onlay – titanium Not a covered benefit identification must include B or
L surface
FIXED PARTIAL DENTURE RETAINERS – CROWNS
D6710 Retainer Crown – indirect resin-based composite Not a covered benefit None
D6720 Retainer Crown – resin with high noble metal Not a covered benefit Tooth identification
Retainer Crown – resin with predominantly base
D6721 Not a covered benefit Tooth identification
metal
D6722 Retainer Crown – resin with noble metal Not a covered benefit Tooth identification
D6740 Retainer Crown – porcelain/ceramic Not a covered benefit Tooth identification
D6750 Retainer Crown – porcelain fused to high noble Not a covered benefit Tooth identification

Retainer Crown – porcelain fused to predominantly

D6751 Not a covered benefit Tooth identification
base metal

D6752 Retainer Crown – porcelain fused to noble metal Not a covered benefit Tooth identification
Retainer crown – porcelain fused to titanium and
D6753 Not a covered benefit Tooth identification
titanium alloys
D6780 Retainer Crown – ¾ cast high noble metal Not a covered benefit Tooth identification
D6781 Retainer Crown – ¾ cast predominately base metal Not a covered benefit Tooth identification
D6782 Retainer Crown – ¾ cast noble metal Not a covered benefit Tooth identification
D6783 Retainer Crown – ¾ porcelain/ceramic Not a covered benefit Tooth identification
D6784 Retainer crown ¾ – titanium and titanium alloys Not a covered benefit Tooth identification
D6790 Retainer Crown – full cast high noble metal Not a covered benefit Tooth identification
D6791 Retainer Crown – full cast predominantly base metal Not a covered benefit Tooth identification
D6792 Retainer Crown – full cast noble metal Not a covered benefit Tooth identification

57
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Interim retainer crown – further treatment or

D6793 completion of diagnosis necessary prior to final Not a covered benefit Tooth identification
impression
D6794 Retainer Crown – titanium Not a covered benefit Tooth identification
OTHER FIXED PARTIAL DENTURE SERVICES
D6920 Connector bar No limitations None
D6930 Re-cement or re-bond bridge No limitations Tooth identification
D6940 Stress breaker Not a covered benefit None
D6950 Precision attachments Not a covered benefit None

Fixed partial denture (bridge) repair, necessitated by

D6980 No limitations Tooth identification
restorative material failure

D6985 Pediatric fixed partial denture Not a covered benefit Arch identification
D6999 Unspecified fixed prosthodontic procedure, by report Not a covered benefit Detailed narrative

Oral and Maxillofacial Surgery

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

EXTRACTIONS: Includes local anesthesia, suturing if needed, and routine post operative care. Bone grafts (D4263, D4264, D4265) and GTR
membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

D7111 Extraction – coronal remnants, deciduous tooth One per tooth per lifetime Tooth identification

58
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Extraction – erupted tooth or exposed root (elevation

D7140 One per tooth per lifetime Tooth identification
and/or forcep removal)

SURGICAL EXTRACTIONS (Includes local anesthesia, suturing, if needed, and routine postoperative care)

Surgical removal of an erupted tooth requiring

D7210 removal of bone and/or sectioning of tooth and One per tooth per lifetime Tooth identification
including elevation of mucoperiosteal flap if indicated

D7220 Removal of impacted tooth – soft tissue One per tooth per lifetime Tooth identification

D7230 Removal of impacted tooth – partially bony One per tooth per lifetime Tooth identification

D7240 Removal of impacted tooth – completely bony One per tooth per lifetime Tooth identification

Removal of impacted tooth – completely bony, with

D7241 One per tooth per lifetime Tooth identification
unusual surgical complications

Surgical removal of residual tooth roots (cutting

D7250 One per tooth per lifetime Tooth identification
procedure)

D7251 Coronectomy: intentional partial tooth removal One per tooth per lifetime Tooth identification

OTHER SURGICAL PROCEDURES

D7260 Oroantral fistula closure No limitations None

D7261 Primary closure of a sinus perforation No limitations None

59
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Tooth reimplantation and/or stabilization of

D7270 Not a covered benefit Tooth identification
accidentally evulsed or displaced tooth

Tooth transplantation (includes reimplantation from

D7272 Not a covered benefit Tooth identification
one site to another and splinting and/or stabilization)

D7280 Surgical access of unerupted tooth One per tooth per lifetime Tooth identification

Mobilization of erupted or mal-positioned tooth to aid

D7282 Not a covered benefit Tooth identification
eruption

Placement of device to facilitate eruption of impacted

D7283 Tooth identification
tooth

D7285 Incisional biopsy of oral tissue – hard (bone, tooth) No limitations covered through age 18 None

D7286 Incisional biopsy of oral tissue – soft (all others) No limitations covered through age 19 None

D7287 Cytology exfoliative sample collection Not a covered benefit None

D7288 Brush biopsy – transepithelial sample collection Not a covered benefit None

Surgical repositioning of teeth – grafting procedures

D7290 Not a covered benefit Tooth identification;
are additional

60
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Transseptal fiberotomy/supra crestal fiberotomy, by

D7291 Not a covered benefit Tooth identification;
report

Surgical placement of temporary anchorage device

D7292 Not a covered benefit None
(screw retained plate) requiring flap

Removal of temporary anchorage device [screw

D7298 Not a covered benefit None
retained plate], requiring flap

Removal of temporary anchorage device, requiring

D7299 Not a covered benefit None
flap

D7300 Removal of temporary anchorage device without flap Not a covered benefit None

ALVEOPLASTY: SURGICAL PREPARATION OF RIDGE FOR DENTURES

Alveoloplasty in conjunction with extractions – per Tooth and Quadrant

D7310 No limitations
quadrant identification

Alveoloplasty in conjunction with extractions – one to

D7311 No limitations Tooth identification
three teeth or tooth spaces, per quadrant

Alveoloplasty, not in conjunction with extractions – Tooth and Quadrant

D7320 No limitations
per quadrant identification

61
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Alveoloplasty, not in conjunction with extractions –

D7321 No limitations Tooth identification
one to three teeth or tooth spaces, per quadrant

VESTIBULOPLASTY

No limitations. Consultant review required

Vestibuloplasty – ridge extension (secondary
D7340 when performed in conjunction with other None
epithelialization)
services on the same day.

Vestibuloplasty – ridge extension (incl. soft tissue

No limitations. Consultant review required
grafts, muscle re-attachment, revision of soft tissue
D7350 when performed in conjunction with other None
attachment and management of hypertrophied and
services on the same day.
hyperplastic tissue)

Surgical placement of temporary anchorage devise

D7293 Not a covered benefit None
requiring flap

Surgical placement of temporary anchorage device

D7294 Not a covered benefit None
without flap

Harvest of bone for use in autogenous grafting

D7295 Not a covered benefit Tooth identification
procedures

62
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Corticotomy – 1 to 3 teeth or tooth spaces, per

D7296 Not a covered benefit Tooth identification
quadrant

Corticotomy – 4 or more teeth or tooth spaces, per

D7297 Not a covered benefit Quadrant identification
quadrant

SURGICAL EXCISION OF REACTIVE SOFT TISSUE LESIONS

D7410 Excision of benign lesion, up to 1.25 cm No limitations None

D7411 Excision of benign lesion > 1.25 cm No limitations None

D7412 Excision of benign lesion; complicated Not a covered benefit None

D7413 Excision of malignant lesion, up to 1.25 cm Not a covered benefit None

D7414 Excision of malignant lesion > 1.25 cm Not a covered benefit None

D7415 Excision of malignant lesion, complicated Not a covered benefit None

SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS

63
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Excision of malignant tumor-lesion, diameter up to

D7440 Not a covered benefit None
1.25 cm

Excision of malignant tumor-lesion, diameter >1.25

D7441 No limitations None
cm

Removal of benign odontogenic cyst or tumor lesion,

D7450 No limitations None
diameter up to 1.25 cm

Removal of benign odontogenic cyst or tumor, lesion

D7451 No limitations None
diameter > 1.25 cm

Removal of benign non-odontogenic cyst or tumor,

D7460 Not a covered benefit None
lesion, diameter up to 1.25 cm

Processing and interpretation of exfoliative cytologic

D7461 smears, including preparation and transmission of Not a covered benefit None
written report

Destruction of lesion(s) by physical or chemical

D7465 Not a covered benefit None
methods, by report

64
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

EXCISION OF BONE TISSUE

D7471 Removal of exostosis – per site No limitations None

D7472 Removal of torus palatinus No limitations None

D7473 Removal of torus mandibularis No limitations None

D7485 Surgical reduction of osseous tuberosity No limitations None

D7490 Radical resection of maxilla mandible Not a covered benefit None

SURGICAL INCISION

Incision and drainage of abscess – intraoral soft No limitations. Not covered in conjunction
D7510 Tooth and Arch identification
tissue with completed root canal treatment.

Incision and drainage of abscess intraoral soft tissue

D7511 – complicated (includes drainage of multiple fascial Not a covered benefit None
spaces)

Incision and drainage of abscess – extraoral soft

D7520 Not a covered benefit None
tissue

65
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Incision and drainage of abscess extraoral soft tissue

D7521 complicated (includes drainage of multiple fascial Not a covered benefit None
spaces)

Removal of foreign body, mucosa, skin, or

D7530 No limitations None
subcutaneous alveolar tissue

Removal of reaction-producing foreign bodies –

D7540 Not a covered benefit None
musculoskeletal system

Partial ostectomy, sequestrectomy for removal of

D7550 Not a covered benefit None
nonvital bone

Maxillary sinusotomy for removal of tooth fragment or

D7560 No limitations None
foreign body

TREATMENT OF FRACTURES – SIMPLE

Maxilla – open reduction (teeth immobilized, if

D7610 Not a covered benefit None
present)

66
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Maxilla – closed reduction (teeth immobilized, if

D7620 Not a covered benefit None
present)

Mandible – open reduction (teeth immobilized, if

D7630 Not a covered benefit None
present)

Mandible – closed reduction (teeth immobilized, if

D7640 Not a covered benefit None
present)

D7650 Malar and/or zygomatic arch – open reduction Not a covered benefit None

D7660 Malar and/or zygomatic arch – closed reduction Not a covered benefit None

Alveolus – closed reduction, may include stabilization

D7670 Not a covered benefit None
of teeth

Alveolus – open reduction, may include stabilization

D7671 Not a covered benefit None
of teeth

67
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Facial bones – complicated reduction with fixation

D7680 Not a covered benefit None
and multiple surgical approaches

TREATMENT OF FRACTURES – COMPOUND

D7710 Maxilla – open reduction, stabilization of teeth Not a covered benefit None

D7720 Maxilla – closed reduction Not a covered benefit None

D7730 Mandible – open reduction Not a covered benefit None

D7740 Mandible – closed reduction Not a covered benefit None

D7750 Malar and/or zygomatic arch – open reduction Not a covered benefit None

D7760 Malar and/or zygomatic arch – closed reduction Not a covered benefit None

D7770 Alveolus – open reduction stabilization of teeth Not a covered benefit None

D7771 Alveolus – closed reduction, stabilization of teeth Not a covered benefit None

Facial bones – complicated reduction with fixation

D7780 Not a covered benefit None
and multiple surgical approaches

68
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS: Procedures that are an
integral part of the primary procedure should not be reported separately.

D7810 Open reduction of dislocation Not a covered benefit None

D7820 Closed reduction of dislocation Not a covered benefit None

D7830 Manipulation under anesthesia Not a covered benefit None

D7840 Condylectomy Not a covered benefit None

D7850 Surgical disectomy; with or without implant Not a covered benefit None

D7852 Disc repair Not a covered benefit None

D7854 Synovectomy Not a covered benefit None

D7856 Myotomy Not a covered benefit None

D7858 Joint reconstruction Not a covered benefit None

D7860 Arthrotomy Not a covered benefit None

D7865 Arthroplasty Not a covered benefit None

69
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D7870 Arthrocentesis Not a covered benefit None

D7871 Non-anthroscopic lysis and lavage Not a covered benefit None

D7872 Arthroscopy – diagnosis Not a covered benefit None

D7873 Arthroscopy – surgical: lavage and lysis of adhesions Not a covered benefit None

Arthroscopy – surgical: disc repositioning and

D7874 Not a covered benefit None
stabilization

D7875 Arthroscopy – surgical: synovectomy Not a covered benefit None

D7876 Arthroscopy – surgical: disectomy Not a covered benefit None

D7877 Arthroscopy – surgical: debridement Not a covered benefit None

D7880 Occlusal orthotic device, by report Not a covered benefit None

D7881 Occlusal orthotic device adjustment Not a covered benefit None

D7899 Unspecified TMD therapy, by report Not a covered benefit None

70
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

REPAIR OF TRAUMATIC WOUNDS

D7910 Suture of recent small wounds up to 5 cm Not a covered benefit None

COMPLICATED SUTURING – Reconstruction requiring delicate handling of tissues and wide undermining for
meticulous closure

D7911 Complicated suture up to 5 cm Not a covered benefit None

D7912 Complicated suture > 5 cm Not a covered benefit None

OTHER REPAIR PROCEDURES

Skin grafts (identify defect covered, location, and type

D7920 Not a covered benefit None
of graft)

Collection and application of autologous blood

D7921 Not a covered benefit None
concentrate product

Placement of intra-socket biological dressing to aid in

D7922 Always integral None
hemostasis or clot stabilization, per site

D7940 Osteoplasty – for orthognathic deformities Not a covered benefit None

71
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D7941 Osteotomy – mandibular rami Not a covered benefit None

Osteotomy – mandibular rami with bone graft;

D7943 Not a covered benefit None
includes obtaining the graft

Osteotomy – segmented or sub-apical, per sextant or

D7944 Not a covered benefit None
quadrant

D7945 Osteotomy – body of mandible Not a covered benefit None

D7946 LeFort I (maxilla – total) Not a covered benefit None

D7947 LeFort I (maxilla – segmented) Not a covered benefit None

LeFort II or LeFort III (osteoplasty of facial bones for

D7948 Not a covered benefit None
midface hypoplasia or retrusion) – without bone graft

D7949 LeFort II or LeFort II – with bone graft Not a covered benefit None

Osseous, osteoperiosteal, or cartilage graft of the

D7950 mandible or maxilla, autogenous or nonautogenous, Not a covered benefit None
by report

72
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Sinus augmentation with bone or bone substitutes via

D7951 Not a covered benefit None
a lateral open approach

D7952 Sinus augmentation via a vertical approach Not a covered benefit None

Bone replacement graft for ridge preservation – per

D7953 Not a covered benefit None
site

D7955 Repair of maxillofacial soft and/or hard tissue defect Not a covered benefit None

Tooth identification; Detailed

D7961 buccal / labial frenectomy (frenulectomy) No limitations
narrative

Tooth identification; Detailed

D7962 lingual frenectomy (frenulectomy) No limitations
narrative

Tooth identification; Detailed

D7963 Frenuloplasty Not a covered benefit
narrative

Arch identification; Operative

D7970 Excision of hyperplastic tissue – per arch No limitations
report

D7971 Excision of pericoronal gingiva No limitations None

73
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D7972 Surgical reduction of fibrous tuberosity Not a covered benefit None

D7979 Non-surgical sialolithotomy Not a covered benefit None

D7980 Sialolithotomy Not a covered benefit None

D7981 Excision of salivary gland, by report Not a covered benefit None

D7982 Sialodochoplasty Not a covered benefit None

D7983 Closure of salivary fistula Not a covered benefit None

D7990 Emergency tracheotomy Not a covered benefit None

D7991 Coronoidectomy Not a covered benefit None

D7994 surgical placement: zygomatic implant Not a covered benefit None

Tooth identification Quadrant

D7995 Synthetic graft, mandible or facial bones, by report Not a covered benefit
identification

Implant – mandible for augmentation purposes

D7996 Not a covered benefit None
(excluding alveolar ridge), by report

74
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Appliance removal (not by dentist who place

D7997 Not a covered benefit None
appliance), includes removal of archbar

Intraoral placement of a fixation device not in

D7998 Not a covered benefit None
conjunction with a fracture

D7999 Unspecified oral surgery procedure, by report Not a covered benefit None

75
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
Orthodontic Services
Orthodontic Benefit Administration
Limited Orthodontic Treatment
Use these codes for treatment with a limited objective, not 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 forgo more comprehensive therapy.
Interceptive Orthodontic Treatment
Use these codes for procedures to lessen the severity or future effects of a malformation and to eliminate its cause (e.g., the redirection of an ectopically
erupted tooth, correction of isolated dental cross-bite, or recovery of recent minor space loss where overall space is adequate).
Comprehensive Orthodontic Treatment
Use these codes when there are multiple phases of treatment provided at different stages of dentofacial development. For example, use of an activator is
generally stage one of a two-stage treatment; in this situation, placement of fixed appliances will generally be stage two of a two-stage treatment. List both
treatment phases as comprehensive treatment modified by the stage of dental development.

How to Submit Claims - Please follow these guidelines when submitting claims for orthodontic treatment:
Limited, Interceptive and Minor Treatment. Submit a claim with the appropriate CDT procedure code, including the total treatment fee and the
placement date of the appliance. We will make payment after receipt of initial claim for treatment.
Comprehensive Treatment. One installment equal to 25% of the lifetime maximum; pro-rated payments continue monthly until the treatment has ended
or a new treatment plan including complete treatment plan information is submitted. For patients whose comprehensive treatment started after their
orthodontic benefits became effective, submit the claim with the appropriate CDT procedure code, including the treatment charge and the date treatment
began. Payment will be prorated by comparing the banding date to the effective date of coverage and remaining length of treatment. (Accumulation
transfers will be considered if provided by prior carrier.) If comprehensive treatment began before the patient’s orthodontic benefits became effective,
submit the monthly visits and your monthly fee using the appropriate CDT procedure code. When submitting claims for the services included in orthodontic
records, itemize the appropriate CDT procedure code for each service (e.g., radiographs, evaluation, study models) with your usual fee. If you have
questions regarding a patient’s coverage, effective dates, or benefits, call the Dental Information Center at 1-888-224-5213

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

ORTHODONTICS
D8010 Limited orthodontic treatment of primary dentition Limited to dependent child through age 18 None
D8020 Limited orthodontic treatment of transitional dentition Limited to dependent child through age 18 None
D8030 Limited orthodontic treatment of adolescent dentition Limited to dependent child through age 18 None
D8040 Limited orthodontic treatment of adult dentition Limited to dependent child through age 18 None

76
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Comprehensive orthodontic treatment of transitional

D8070 Limited to dependent child through age 18 None
dentition
Comprehensive orthodontic treatment of adolescent
D8080 Limited to dependent child through age 18 None
dentition
Comprehensive orthodontic treatment of adult
D8090 Limited to dependent child through age 18 None
dentition
Removable appliance therapy to control harmful
D8210 Limited to dependent child through age 18 None
habits

D8220 Fixed appliance therapy to control harmful habits Limited to dependent child through age 18 None

OTHER ORTHODONTIC SERVICES

Pre-orthodontic treatment examination to monitor
D8660 Not a covered benefit None
growth and development
D8670 Periodic orthodontic treatment visit Not a covered benefit None
Orthodontic retention (removal of appliances,
D8680 Limited to dependent child through age 18 None
construction and placement of retainer(s))
D8681 Removable orthodontic retainer adjustment Not a covered benefit None
Removal of fixed orthodontic appliances for reasons
D8695 Not a covered benefit None
other than completion of treatment
D8696 Repair of orthodontic appliance – maxillary Not a covered benefit Arch identification
D8697 Repair of orthodontic appliance – mandibular Not a covered benefit Arch identification
D8698 Re-cement or re-bond fixed retainer – maxillary Covered with ortho benefit Arch identification
D8699 Re-cement or re-bond fixed retainer - mandibular Covered with ortho benefit Arch identification
Repair of fixed retainer, includes reattachment –
D8701 Not a covered benefit Arch identification
maxillary
Repair of fixed retainer, includes reattachment –
D8702 Not a covered benefit Arch identification
mandibular
D8703 Replacement of lost or broken retainer – maxillary Not a covered benefit Arch identification
77
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D8704 Replacement of lost or broken retainer – mandibular Not a covered benefit Arch identification
Unspecified orthodontic procedure, by report; Used
D8999 Not a covered benefit None
for procedures not adequately described by a code

Adjunctive Service

Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

UNCLASSIFIED TREATMENT

Not a covered benefit when reported with

Palliative (emergency) treatment of dental pain – Tooth Quadrant or Arch
D9110 other definitive services on same
minor procedure identification
treatment date

D9120 Fixed partial denture sectioning Not a covered benefit Tooth identification

Temporomandibular joint dysfunction – non-invasive

D9130 Not a covered benefit None
physical therapies

ANESTHESIA

Local anesthesia not in conjunction with operative or Considered part of total fee for non-
D9210 None
surgical procedures surgical or surgical services

Considered part of total fee for non-

D9211 Regional block anesthesia None
surgical or surgical services

78
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Considered part of total fee for non-

D9212 Trigeminal division block anesthesia None
surgical or surgical services

Local anesthesia in conjunction with operative or Considered part of total fee for non-
D9215 None
surgical procedures surgical or surgical services

Evaluation for moderate sedation, deep sedation or

D9219 Not a covered benefit None
general anesthesia
Covered when provided with covered
surgical procedure. The number of 15
D9222 Deep sedation/general anesthesia – first 15 minutes minute increments need to be reported. None
Contract limitation of 60 minutes per
session.
Covered when provided with covered
surgical procedure. The number of 15
Deep sedation/general anesthesia each 15 minute
D9223 minute increments need to be reported. None
increment
Contract limitation of 60 minutes per
session.

D9230 Administration of nitrous oxide/anxiolysis, analgesia Not a covered benefit None

Covered when provided with covered

surgical procedures. The number of 15
Intravenous moderate (conscious) sedation/analgesia-
D9239 minute increments need to be reported. None
first 15 minutes
Contract limitation of 60 minutes per
session.

79
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Covered when provided with covered

surgical procedures. The number of 15
Intravenous moderate (conscious) sedation/analgesia
D9243 minute increments need to be reported. None
– each 15 minute increment
Contract limitation of 60 minutes per
session.

Non-intravenous (conscious) sedation. This includes

D9248 Not a covered benefit None
non-IV minimal and moderate sedation.

PROFESSIONAL CONSULTATION

Consultation (diagnostic service by dentist or

D9310 physician other than the practitioner providing Covered through age 18 None
treatment)

D9311 Consultation with a medical health care professional Not a covered benefit None

PROFESSIONAL VISITS

D9410 House call Not a covered benefit None

D9420 Hospital or ambulatory surgical center call Not a covered benefit None

Office visit for observation during regular scheduled

D9430 Not a covered benefit None
hours – no other services performed

D9440 Office visit – after regularly scheduled hours Not a covered benefit None

Case presentation, extensive and detailed treatment

D9450 Not a covered benefit None
planning

80
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

DRUGS

D9610 Therapeutic drug injection, by report Not a covered benefit None

Therapeutic parenteral drugs, two or more

D9612 Not a covered benefit None
administrations, different medications
Infiltration of sustained release therapeutic drug – per
D9613 Not a covered benefit None
quadrant

D9630 Other drugs and/or medicaments, by report Not a covered benefit None

MISCELLANEOUS SERVICES

D9910 Application of desensitizing medicament Not a covered benefit Tooth identification

Application of desensitizing resin for cervical and/or

D9911 Not a covered benefit Tooth identification
root surface, per tooth

D9912 Pre-visit patient screeninge. Not a covered benefit Tooth identification

D9920 Behavior management, by report Not a covered benefit None

Treatment of complications (post-surgical) - unusual

D9930 Not a covered benefit None
circumstances, by report

Cleaning and inspection of removable complete

D9932 Always integral. None
denture, maxillary

Cleaning and inspection of removable complete

D9933 Always integral. None
denture, mandibular

81
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Cleaning and inspection of removable partial denture,

D9934 Always integral. None
maxillary

Cleaning and inspection of removable partial denture,

D9935 Always integral. None
mandibular

D9941 Fabrication of athletic mouth-guard Not a covered benefit None

D9942 Repair and/ or reline of occlusal guard Not a covered benefit None

D9943 Occlusal guard adjustment Not a covered benefit None

D9944 Occlusal guard – hard appliance, full arch Not a covered benefit Arch identification

D9945 Occlusal guard – soft appliance, full arch Not a covered benefit Arch identification

D9946 Occlusal guard – hard appliance, partial arch Not a covered benefit Arch identification

Custom sleep apnea appliance fabrication and

D9947 Not a covered benefit None
placement

D9948 Adjustment of custom sleep apnea appliance Not a covered benefit None

D9949 Repair of custom sleep apnea appliance Not a covered benefit None

D9950 Occlusion analysis - mounted case Not a covered benefit None

D9951 Occlusal adjustment - limited Not a covered benefit None

D9952 Occlusal adjustment - complete Not a covered benefit None

82
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

D9961 Duplicate/copy patient’s records Not a covered benefit None

D9970 Enamel microabrasion Not a covered benefit None

Odontoplasty 1-2 teeth; includes removal of enamel

D9971 Not a covered benefit None
projections

D9972 External bleaching – per arch performed in office Not a covered benefit None

D9973 External bleaching – per tooth Not a covered benefit None

D9974 Internal bleaching – per tooth Not a covered benefit None

External bleaching for home application per arch;

D9975 Not a covered benefit None
includes materials and fabrication of custom trays

D9985 Sales tax Not a covered benefit None

D9986 Missed appointment Not a covered benefit None

D9987 Cancelled appointment Not a covered benefit None

D9990 Certified translation or sign-language services per visit Not a covered benefit None

Dental case management – addressing appointment

D9991 Not a covered benefit None
compliance barriers

D9992 Dental case management – care coordination Not a covered benefit None

D9993 Dental case management – motivational interviewing Not a covered benefit None

83
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
 Submission Requirements:
CDT Code Description of Service Procedure Guidelines
Participating Providers

Dental case management – patient education to

D9994 Not a covered benefit None
improve oral health literacy

No limitations; allowance is applied to the

D9995 Teledentistry- synchronous; real-time encounter Bill with D0140
maximum

Teledentistry- asynchronous; information stored and

D9996 Not a covered benefit None
forwarded to dentist for subsequent review

Dental case management – patients with special

D9997 Not a covered benefit None
health care needs

Tooth Quadrant or Arch

D9999 Unspecified adjunctive procedure by report Not a covered benefit
identification

84
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular details will vary from
plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit plans include Enhanced benefits.
Specific Benefit
Limitations

Integral Services
The integral services below are considered part of another service. No additional allowance will be paid if they are billed as a separate
service.
1. Supragingival scaling integral to a prophylaxis
2. Prophylaxis on the same day as a periodontal maintenance visit (D4910) or periodontal treatment, including surgery
3. Prophylaxis on the same day as a scaling and root planing (D4341, D4342), regardless of the number of quadrants or teeth reported
4. Sealants on the same day and same surface as a resin restoration
5. Periapical X-rays taken on the same day as a panorex (D0330)
6. Periapical X-rays and/or bitewings taken on the same day as a full series (D0210)
7. Adjunctive procedures that are integral to crowns, inlays and onlays
8. Intraoral I&D (D7510) with root canal therapy
9. A diagnostic X-ray taken the same day as the initial root canal therapy is covered.
10. Pulpotomies, in conjunction with root canal therapy by the same dentist within forty-five (45) days prior to root canal therapy completion date,
are integral to root canal therapy.
11. Payment is made for the most extensive periodontal surgical procedure that includes any lesser procedures on the same date. If procedures
are fragmented, the lesser procedure will be denied as integral.
12. Scaling and root planing on the same date as surgical periodontal procedures
13. Periodontal maintenance when reported with scaling and root planing on the same date regardless of the number of quadrants or teeth
reported
14. Periodontal maintenance on the same day and same dentist as surgical periodontal procedures
15. Complete or partial denture adjustments within six months of insertion
16. Recementation of crowns and bridges when provided within twelve (12) months following insertion by the same dentist (unless there is an
indication of root canal therapy) and then it is covered once per twelve (12) months thereafter
17. Temporary cementation of crowns or bridges
18. Frenulectomy (D7960) when provided the same date, by the same dentist, and to the same area of the mouth is integral to soft tissue grafts.
19. Apical curettage and small odontogenic cysts are denied as being integral to apicoectomies.
20. Rebasing/relining of full or partial denture within six months of insertion by the same dentist
21. Small cysts are denied as being integral to extractions and surgical procedures in the same area of the mouth by the same dentist
22. Crown lengthening on the same day by the same dentist and same area as osseous surgery. The osseous surgery will be denied as being
integral to the crown lengthening.
23. Palliative emergency treatment is denied as being integral to definitive treatment when provided on the same day.
24. Myofunctional therapy involving exercise / physical therapy is integral to orthodontic treatment.
85
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
25. Isolation of tooth with rubber dam
26. Local and block anesthesia

Service Limitations
The following services are specifically limited with the following conditions:
1. Sealants (D1351) and preventive resin restorations (1352) are covered for dependent children through age fifteen (15) on permanent first and
second molars, and are limited to one per three-year period (a sealant cannot replace a preventive resin restoration).
2. Cephalometric X-rays (D0340) are covered once per lifetime with all others denying as integral service. Cephalometric X-rays are not covered
at all unless the member’s schedule of benefits specifically indicates coverage for orthodontic services (Service Category D).
3. If the allowance for the combination of multiple periapicals, bitewings or full series of X-rays exceeds the allowance for a full series, they will
be combined to a full series.
4. Vertical bitewing X-rays (seven [7] to eight [8] films, D0277) are paid with the same benefit limitations as four bitewing X-rays (D0274).
5. Sedative restorations (D2940) are allowed as palliative treatment in emergency situations, otherwise they deny as not covered.
6. An allowance is made for pins (D2951) per restoration regardless of the number used, and pins without a restoration are not covered.
7. A crown must be necessary on its own merit, not just because it will support a partial.
8. Scaling and root planing for patients under age nineteen (19) requires diagnostic material submission and a Dental Advisor review.
9. Separate restorations may be allowed on same surface for anterior teeth. Separate lines represent separate restorations. Procedures related
to a restoration are not paid as separate, including repairs/replacements for twelve (12) months.
10. Multiple posterior restorations are paid as one multi-surface restoration when provided on the same day by the same dentist regardless of
being reported as separate restorations.
11. Pins and/or posts reported, in addition to buildup or post and core, are combined to the buildup or post and core.
12. Buildups involving posts must be preceded by root canal therapy.
13. Incomplete endodontic therapy (Code D3332) of an inoperable or fractured tooth is covered by report.
14. Apicoectomies, in absence of root canal therapy, are denied unless the canals are calcified. Apicoectomy is not allowed within thirty (30) days
of root canal therapy.
15. The final apexification visit includes root canal therapy. If billed separately, the root canal therapy will be combined to the final visit.
16. Pulpotomies are covered only on deciduous teeth, through age five (5) for teeth D – G and N- O and through age eleven (11) for teeth A-C, H-
J, K-M and R-T.
17. Relining and rebasing of full or partial dentures on the same day and the same dentist merges to the rebase procedure. (D5710, D5711,
D5720, D5721).
18. Surgical extractions (D7210) denied for lack of coverage remain denied if submitted as simple extractions (D7111, D7140) unless, on an
inquiry basis, X-rays substantiate that it is a simple extraction.
19. Vestibuloplasty on the same day as other surgical procedures requires Dental Advisor review.
20. Periodontal maintenance is covered if:
a. The patient has periodontal coverage.
b. It follows active periodontal treatment.
86
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
 c. A routine prophylaxis has not been allowed on the same day.
d. The number of periodontal maintenance and prophylaxis procedures does not exceed four per year.
21. Diagnostic X-rays are not covered if there is no documentation in the patient’s records indicating why the radiographs were ordered and/or
what was diagnosed by the dentist upon reviewing the prescribed films.
22. Root canal retreatment (D3346, D3347, and D3348) is allowed only if it has been three (3) years following initial root canal therapy.
23. Removable space maintainers (D1510, D1515) and maintainer repairs are limited to one (1) in a three (3) year period.

Excluded Services
The following services are specifically excluded with no coverage provided:
1. A service, procedure or supply that is not Dentally Necessary or is not listed in the Schedule of Benefits
2. A service, procedure or supply that is not prescribed or rendered by or under the general supervision of a dentist
3. Any treatment, service or supply received for any illness or accidental injury arising out of, or in the course of employment or occupation for
wage, profit or gain, or for injury or illness for which the member receives any benefits from motor vehicle no-fault law, regardless of any
limitations in scope or coverage amount that may apply to his benefits claim under such laws

In the event a claim is paid and subsequently the member files a claim for workers’ compensation benefits as to such claim, or the member
settles a workers’ compensation claim with any workers’ compensation carrier, or otherwise receives any amount toward payment of such a
claim under the Arkansas Workers’ Compensation Law, state or federal workers’ compensation, employers’ liability or occupational disease
law, or motor vehicle no-fault law, the member agrees to reimburse monies to the full extent on such claim.
4. Conditions to which dental treatment is provided by a federal or state government agency (not including medical assistance) or are provided
without cost to any member by a political subdivision or governmental authority (not including plans of insurance or other benefit plans
provided by the federal or state governments to government employees and employees’ dependents)
5. Services of intentional self-inflicted injuries, including drug overdose, where act resulted from not medical condition (physical or mental)
6. Disease contracted or injuries sustained while servicing in the military forces of any nation
7. Any condition for which services, treatment or supplies of any kind are furnished or paid for under Title XVIII (Medicare) or the Social Security
Act, as amended 8. Services, procedures or supplies with respect to congenital mouth malformation or skeletal imbalance, including but not
limited to: a. Treatment related to disharmony of facial bone
b. Treatment related to or required as a result of orthognathic surgery
9. Treatment, services or supplies that are cosmetic in nature or performed on an elective basis (e.g., teeth bleaching, crowns or veneers on
teeth without decay or fracture which would otherwise not require a crown.)
10. Restorative or prosthetic treatment necessitated by attrition, abrasion, or erosion.
11. Prescription drugs
12. Local or block anesthesia, when billed separately

87
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
13. General anesthesia (D9220, D9221) or IV conscious sedation (D9241, D9242), for a non-covered service, as well as simple extractions, or
routine chair-side procedures
14. Any experimental or investigational services or supplies or for any condition or complication arising from or related to the use of such
experimental or investigational services or supplies
Arkansas Blue Cross shall have full discretion to determine whether a dental treatment is experimental or investigational. Any dental treatment
may be deemed experimental or investigational if:
a. Reliable evidence (as defined in the box below) shows that the majority opinion among experts, as stated in the published
authoritative literature, regarding the dental treatment or procedure is that further studies or clinical trials are necessary to determine its
efficacy or its efficacy as compared with a standard means of treatment or diagnosis.
b. Reliable evidence shows that a majority opinion among experts, as stated in the published authoritative literature, regarding the dental
treatment or procedure neither supports nor denies its use for a particular condition or disease.
c. Reliable evidence shows that the majority opinion among experts, as stated in the published authoritative literature, regarding the dental
treatment or procedure should not be used as a first-line therapy for a particular condition or disease.

Reliable Evidence shall mean only:

• The member’s dental records or other information from the treating Dentist(s) or from a consultant(s) regarding the member’s dental
history, treatment or condition;
• The written protocol(s) under which the treatment or procedure is provided to the member;
• Any consent document the member has executed or will be asked to execute, in order to receive the treatment or procedure;
• Published reports and articles in the authoritative dental and scientific literature, signed by or published in the name of a recognized
dental expert,
regarding the treatment or procedure at issue as applied to the injury, illness or condition at issue;
or
• The written protocol(s) used by another facility studying substantially the same dental treatment or procedure
15. The cost to replace a lost, stolen or damaged prosthetic appliance
16. House calls (D9410) and hospital calls (D9420) for dental services
17. Services incurred prior to a member’s effective date or after the termination date of coverage with Arkansas Blue Cross
18. Resorbable fillings (D3230, D3240) on endodontic treated deciduous teeth
19. Any dental or medical services performed by a physician for services covered or otherwise provided to the member by a medical-surgical plan
20. Services that the member incurs at no cost
21. Service that are necessitated by lack of patient cooperation or failure to follow a professionally prescribed treatment plan 22.
Plaque control programs, oral hygiene or dietary instructions
23. Any procedure deemed by the Dental Advisor to be of questionable efficacy
24. Charges for broken appointments
88
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
25. Any dental services or supplies required as the result of any accidental or traumatic injury
26. Any dental services or supplies resulting from an injury or condition caused by another party
27. Dental procedures requiring appliances or restorations that are necessary for full mouth rehabilitation, the restoration of occlusion, or to alter
vertical dimensions of occlusion (except when involving full or partial dentures)
28. Non-intravenous conscious sedation (D9248), analgesia, anxiolysis or inhalation of nitrous oxide (D9230)
29. Services by an immediate relative, defined as a spouse, parents, children, brother, sister or legal guardian of the person who received the
services
30. Duplicate, interim and temporary procedures, devices and appliances (e.g., when a dentist begins a crown and places a temporary crown, and
then submits charges for a permanent crown, coverage for the temporary crown will be denied.)
31. Procedures requiring the presence of a tooth will be denied if history indicates the tooth has been extracted (e.g., a crown is being reported
and the tooth is listed as extracted in history).

32. Gold foil restorations (D2410, D2420, D2430)

33. If a course of treatment is performed by more than one (1) dentist, Arkansas Blue Cross will pay only the charges that would have been made
by a single dentist for those services.
34. Charges for the completion of any insurance forms
35. Applications of desensitizing medicaments, sub-gingival irrigations, and the localized delivery of chemotherapeutic agents (D4381)
36. Double abutments unless there is demonstrated clinical need.
37. Post removal (not in conjunction with endodontic therapy)
38. Autogenous , allogenic or synthetic grafts placed in extraction sites
39. Periodontal provisional splinting, intra-coronal or extra-coronal
40. Any services to restore tooth structure lost in order to rebuild or maintain occlusal surfaces die to mal-aligned or mal-occluded teeth, lost from
wear or for stabilizing the teeth
41. Silicate cements
42. Tissue conditioning (D5850, D5851)
43. Athletic mouth guards (D9941)
44. Precision attachments (D5862, D6950)
45. Gross debridement (D4355)
46. Fiberotomies (D7291)
47. X-ray and intraoral imaging (D0260, D0290, D0310, D0320, D0321, D0322, D0350)
48. Tests/laboratory examination (D0415, D0425, D0472, D0473, D0474, D0480, D0520)
49. Nutritional counseling (D1310)
50. Tobacco counseling (D1320)
51. Replacement of fillings due to mercury sensitivity
52. Prefabricated resin crowns, prefabricated esthetic coated crowns, stainless steel crowns or stainless steel crowns with resin windows for a
primary tooth for patients age 14 or older
89
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
53. Pulpectomy on a permanent tooth
54. Extraoral I & D
55. Direct (D3110) and indirect (D3120) pulp caps
56. Procedure for isolation of tooth with rubber dam
57. Bleaching of teeth (D9972, D9973, & D9974)
58. Intentional re-implantation (D3470)
59. Dressing change (D4920)
60. Maxillofacial prosthetics
61. Precious metal for partial dentures
62. Partial dentures are not covered for patients under age 14.
63. Specialized procedures (D5862, D6920, D6940, D6950, D6975)
64. Alveoloplasty involving less than 5 teeth
65. Tooth transplantation (D7272) or tooth re-implantation (D7270)
66. Excision/destruction of lesions (D7410, D741, D7412, D7413, D7414, D7415, D7440, D7441, D7450, D7451, D7460, D7461)
67. Treatment of simple and compound fractures (D7610 through D7580, D7710 through D7760, D7770, D7771, D7780)
68. Treatment and reduction of dislocation and management of TMJ/TMD (Temporomandibular Joint / Temporomandibular Joint Dysfunction)
(D7810 through
D7899) including diagnostic X-rays, occlusal appliance, and/or splints
69. Consultations (D9310)
70. Drugs, medicaments, and/or injections (D9610, D9630)
71. Behavior management (D9920)
72. Occlusal analysis (D9950) and occlusal adjustments (D9951, D9952)
73. Pulpotomy on permanent tooth will deny as not covered unless there is an indication of an emergency, in which case it is paid as a palliative
treatment. (Not covered within 45 days of RCT)
74. Bridges for patients under age fourteen (14)
75. Replacement of teeth if there is insufficient space
76. Root recovery (D7250) not completely covered by bone, if provided by the same dentist who extracted the tooth
77. Splinted crowns not replacing teeth; abutment crown(s) can be allowed if the tooth is diseased or badly broken down
78. Gross pulpal debridement (D3221)
79. Distal or proximal wedge procedure (D4274)
80. Procedures performed prior to coverage or placed after termination of coverage
81. Palliative emergency treatment (D9110) when definitive treatment is provided by the same dentist on the same day
82. Protective restorations (D2940) Problem focused (D0170)
83. Oral surgery procedures for jaw deformities, resections, etc. (D7920, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949,
D7950, D7955, D7972, D7980, D7981, D7982, D7983, D7990, D7991, D7995, D7996, and D7997)
84. Apically positioned flap procedure (D4245)
90
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.
85. Enamel microabrasion (D9970)
86. Odontoplasty (D9971)
87. Sleep apnea appliances
88. Biologic materials to aid in soft and osseous tissues regeneration (D4265)
89. Provisional pontic (D6253)
90. Provisional retainer crown (D6793)
91. Pediatric partial denture-fixed (D6785)
92. Mobilization of erupted or malpositioned tooth to aid eruption (D7282)
93. Cytology sample collection (D7287)
94. A panoramic film or panorex (D0330) is not covered for children under the age of five (5).
95. Fixed partial denture resin crowns, retainer or pontics on permanent teeth
96. Hospital facility fees for dental services
97. Biopsy of oral tissue (D7285, D7286)
98. Sutures of small wounds and complicated sutures (D7910, D7911, D7912)

91
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage. Not all Benefit
plans include Enhanced benefits.