UnitedHealthcare Community Plan Children's Rehabilitation Services (CRS) Dental Benefit Matrix

Transcription

1 UnitedHealthcare ommunity Plan hildren's Rehabilitation Services (RS) Dental Benefit Matrix PROVIDER WEB PORTAL: Verify eligibility, procedure history, electronically submit claims, authorizations, retro-review, and upload documents including radiographs, clinical notes, general anesthesia logs, etc. directly through your provider secure portal. ontact the provider toll free number to request FREE ONLINE TRAINING for your staff today. Provider Toll Free: Important Addresses Prior Authorization & Retro-Review P.O. Box 2020 Milwaukee, WI laims P.O. Box 2185 Milwaukee, WI orrected laims P.O. Box 541 Milwaukee, WI laims Disputes 1 E. Washington St, Suite 900 Phoenix, AZ Pre-authorization of services is not a guarantee of payment. Retrospective review is not a guarantee of payment. Refer to your fee schedule to determine codes covered for your provider-type. odes listed on this matrix are inclusive of general and specialty provider types; extended code coverage is limited to specialists only. ODES NOT LISTED ARE NON-OVERED. RS_Matrix_Y16 1 of 29

2 Dental services are limited to members under age 21. Patient must have a dentally-eligible medical diagnosis on file (see list of diagnosis on last page). Additionally, member must have been evaluated by a RS clinic, or specialist to determine dental eligibility under the RS program. A RS coverage card is not verification a patient has dental benefits under RS. Please note: The term "Fully Integrated" or "Partially Integrated" does not mean the member has RS dental ; for dental coverage verification visit RS coverage cards verify medical benefits only. For dental eligibility verification, please visit. See last page for information on medical diagnosis codes that may qualify a member for the RS Dental Specialty benefit. *Members without a matching medical qualifying code from this list will not be eligible for the dental portion of the RS program. RS_Matrix_Y16 2 of 29

3 RS ode D0120 Periodic oral evaluation - established patient Benefit once every six months D0140 Limited oral eval - problem focused Not billable within three months of original exam date for the same tooth/quad D0145 Oral eval for patient under 3 yrs of age, and counseling with primary caregiver Benefit once every six months *concurrent flouride varnish placement for all patients under age three D0150 omprehensive oral eval - new or established patient an only be billed once per lifetime per member for each provider group/treating location D0191 Assessment of a patient Benefit once every 12 months. *linical documentation to verify assessment was performed during community outreach or school-based event. D0210 Intraoral-complete series (including bitewings) One FMX or Pano allowed in a three-year period (rolling 36-month period) D0220 Intraoral- periapical first radiographic image D0230 Intraoral- periapical each additional radiographic image D0240 Intraoral- occlusal radiographic image Allowed once every six months D0250 Extraoral- first radiographic image Allowed once every twelve months D0260 Extraoral- each additional radiographic image Allowed once every twelve months D0270 Bitewing- single radiographic image Allowed once every six months D0272 Bitewings- two radiographic images Allowed once every six months D0273 Bitewings- three radiographic images Allowed once every six months D0274 Bitewings- four radiographic images Allowed once every six months D0330 Panoramic radiographic image One FMX or Pano allowed in a 36-month rolling period D0340 ephalometric radiographic image D0350 Oral/facial images : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 3 of 29

4 RS ode D0363- D0391 one beam, T, MRI imaging D0393 Treatment simulation using 3D image volumes D1110 Prophylaxis- Adult Allowed once every six months D1120 Prophylaxis- hild Allowed once every six months D1206 Topical application of fluoride varnish/moderate to high caries risk patients Allowed once every six months *application for all patients aged 3 and under D1208 Topical application of fluoride Allowed once every six months D1351 Sealant - per tooth Permanent first and second molarsteeth#2, 3, 14, 15,1 8, 19, 30, 31 only D1352 Preventive resin restoration in a moderate to high caries risk patient - per tooth Permanent first and second molarsteeth#2, 3, 14, 15,1 8, 19, 30, 31 only D1510 Space maintainer - fixed unilateral - for posterior primary teeth only, which have been lost prematurely One per lifetime per arch. Full arch x-rays & narrative must be included with claim or authorization request. D1515 D1520 D1525 Space maintainer - fixed bilateral - for posterior primary teeth only, which have been lost prematurely Space maintainer - removable unilateral - for posterior primary teeth only Space maintainer - removable bilateral - for posterior primary teeth only D1550 Re-cementation of space maintainer D1555 Removal of fixed space maintainer One per lifetime per arch. Full arch x-rays & narrative must be included with claim or authorization request. One per lifetime per arch. Full arch x-rays & narrative must be included with claim or authorization request. One per lifetime per arch. Full arch x-rays & narrative must be included with claim or authorization request. Not billable within six months of delivery date for the same tooth/quad, by the same provider group. Not billable by the same provider group that originally placed the appliance. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 4 of 29

5 RS ode RESTORATIVE Multiple surface restorations on a tooth (whether connecting surfaces or not) on the same date of service is reimbursed by the total number of surfaces restored. Replacement of restoration and other services within a 2 year period at the same office or an associate office is not billable D2140 Amalgam - one surface, primary or permanent Allowed once per surface in a two year period D2140 Amalgam - one surface, primary or permanent Allowed once per surface in a two year period D2150 Amalgam - two surfaces, primary or permanent Allowed once per surface in a two year period D2160 Amalgam - three surfaces, primary or permanent Allowed once per surface in a two year period D2161 Amalgam - four surfaces, primary or permanent Allowed once per surface in a two year period D2330 Resin-based composite - one surface, anterior Allowed once per surface in a two year period D2331 Resin-based composite - two surfaces, anterior Allowed once per surface in a two year period D2332 Resin-based composite - three surfaces, anterior Allowed once per surface in a two year period D2335 Resin-based composite - four or more surfaces or involving incisal angel (anterior) Allowed once per surface in a two year period D2390 Resin - based composite crown, anterior Periapical x-ray of tooth showing coronal and root surfaces, and clinical notes with retro-review claim or authorization request. D2391 Resin - based composite - one surface, posterior Allowed once per surface in a two year period D2392 Resin - based composite - two surfaces, posterior Allowed once per surface in a two year period D2393 Resin - based composite - three surfaces, posterior Allowed once per surface in a two year period D2394 Resin - based composite - four or more surfaces, posterior Allowed once per surface in a two year period D2740 rown - porcelain/ceramic substrate overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. Alternate code D2751 will be given during claim adjudication. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 5 of 29

6 ode RS D2750 rown - porcelain fused to high noble metal D2751 rown - porcelain fused to predominantly base metal D2752 rown - porcelain fused to noble metal D2790 rown - full cast high noble metal D2791 rown - full cast predominantly base metal D2792 rown - Full cast noble metal overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. Alternate code D2751 will be given during claim adjudication. overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. Alternate code D2751 will be given during claim adjudication. overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. overed for members ages only. Post-operative periapical x-ray of completed root canal with claim. Pre-authorization of service does not guarantee payment. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 6 of 29

7 RS ode D2910 Re-cement inlay,onlay, or partial coverage restoration linical notes and narrative with authorization request of retro-review claim. Retro-review is not a guarantee of payment. D2915 Re-cement cast or prefabricated post and core linical notes and narrative with authorization request of retro-review claim. Retro-review is not a guarantee of payment. D2920 Re-cement crown Not billable within six months of delivery date for the same tooth/quad, by the same provider group. D2921 Reattachment of tooth fragment, incisal edge or cusp Once per two year period, per tooth D2930 Prefabricated stainless steel crown - primary tooth overed for primary posterior teeth only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. D2931 Prefabricated stainless steel crown - permanent tooth overed for posterior permanent teeth only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. D2932 Prefabricated resin crown Primary teeth covered for members aged 1-4 only. Age limitations apply to teeth D, E, F, G, N, O, P, Q only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. Once per two years period, per tooth. D2933 Prefabricated stainless steel crown with resin window Primary teeth covered for members aged 1-4 only. Age limitations apply to teeth D, E, F, G, N, O, P, Q only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. Once per two years period, per tooth. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 7 of 29

8 RS ode D2934 Prefabricated esthetic coated stainless steel crown - primary tooth Primary teeth covered for members aged 1-4 only. Age limitations apply to teeth D, E, F, G, N, O, P, Q only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. Once per two years period, per tooth. D2940 Protective restoration - sedative fillings Not covered when done in conjunction with pulpotomies, root canals, and/or permanent restorations. linical notes, and periapical x-ray with retro-review claim. D2941 Interim therapeutic restoration primary dentition Not covered when done in conjunction with pulpotomies, root canals, and/or permanent restorations. linical notes, and periapical x-ray with retro-review claim. D2949 Restorative foundation for an indirect restoration Once per two year period, per tooth D2950 ore build-up, including any pins Endodontically treated teeth only. Post-op periapical x-ray of completed root canal therapy with pre-authorization D2951 Pin retention - per tooth, in addition to restoration Endodontically treated teeth only. Post-op periapical x-ray of completed root canal therapy with pre-authorization D2952 Post and core in addition to crown Endodontically treated teeth only. Post-op periapical x-ray of completed root canal therapy with pre-authorization D2954 Prefabricated post and core in addition to crown Endodontically treated teeth only. Post-op periapical x-ray of completed root canal therapy with pre-authorization : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 8 of 29

9 ode RS D2955 Post removal D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap -indirect (excluding final restoration) D3220 D3222 D3230 D3240 D3310 Therapeutic pulpotomy (excluding final restoration), primary and permanent teeth (not to used for apexogenesis) Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development Pulpal therapy (resorbable filling)- anterior, primary tooth (excluding restoration) Pulpal therapy (resorbable filling)- posterior, primary tooth (excluding restoration) Endodontic therapy, anterior tooth (excluding final restoration) Periapical x-ray of tooth showing coronal and root surfaces, and clinical notes with retro-review claim or authorization request. Not covered if done in conjunction with permanent restoration. Not covered if done in conjunction with permanent restoration. Primary teeth covered for members aged 0-4 only. Age limitations apply to teeth D, E, F, G, N, O, P, Q only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. Once per two years period, per tooth. Periapical x-ray of tooth showing coronal and root surfaces, and clinical notes with retro-review claim or authorization request. Primary teeth covered for members aged 0-4 only. Age limitations apply to teeth D, E, F, G, N, O, P, Q only. Periapical x-ray showing tooth crown and root structure with authorization request, or retro-review claim. Once per two years period, per tooth. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 9 of 29

10 ode D3320 D3330 Endodontic theraphy, bicuspid tooth (excluding final restoration) Endodontic theraphy, molar tooth (excluding final restoration) RS D3331 Treatment of root canal obstruction; non-surgical access D3332 Incomplete endodontic therapy; inoperable or fractured D3346 Retreatment of previous root canal therapy - anterior Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 10 of 29

11 ode RS D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy - molar D3351 D3352 D3353 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations root resorption, etc.) Apexification/recalcification - interim medication (apical closure/calcific repair of perforations root resorption, etc.) Apexification/recalcification - final visit (includes completed root canal therapy) Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Periapical of completed root canal for payment of claim. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 11 of 29

12 ode RS D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery molar- (first root) D3426 Apicoectomy/ periradicular surgery - each additional root D3430 Retrograde filling - per root Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 12 of 29

13 ode RS D3450 Root amputation - per root D3470 Intentional replantation (including necessary splinting) D3920 D4210 D4211 Hemisection (including any root removal), not including root canal therapy Gingivectomy or gingivoplacty - 4 or more contiguous teeth or tooth bounded spaced per quadrant Gingivectomy or gingivoplasty, one to three teeth, per quadrant Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. Periapical x-ray showing tooth coronal and root structure with authorization request, or retro-review claim. Additionally, clinical notes and narrative. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 13 of 29

14 ode D4240 D4241 Gingival flap procedure, including root planning, four or more contiguous teeth or bounded spaces per quadrant Gingival flap procedure, including root planning, one to three teeth per quadrant RS D4249 linical crown lengthening - hard tissue D4260 D4261 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant Osseous surgery (including flap entry and closure), one to three teeth, per quadrant D4263 Bone replacement graft - first site in quadrant linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. Must be done at least 6 weeks prior to restorative treatment. opy of most recent full mouth x-rays, clinical notes, and narrative are with authorization request or retroreview claim. Retro-review is not a guarantee of payment. linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 14 of 29

15 RS ode D4264 Bone replacement graft - each additional site in quadrant linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4265 Biologic materials to aid in soft and osseous tissue regeneration linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4266 Guided tissue regeneration - resorbable barrier, per site, per tooth linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4267 Guided tissue regeneration - resorbable barrier, per site, per tooth linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4270 Pedicle soft tissue graft procedure linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4273 Subepithelial connective tissue graft procedure linical notes, periodontal charting, copy of most recent full mouth x-rays, and narrative with authorization Retro-review is not a guarantee of payment. D4320 Provisional splinting - intracoronal X-rays & narrative D4321 Provisional splinting - extracoronal X-rays & narrative D4341 Periodontal scaling and root planning, four or more contiguous teeth or bounded teeth spaces per quadrant X-rays, narrative & periodontal charting : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 15 of 29

16 RS ode D4342 Periodontal scaling and root planning - one to three teeth, per quad X-rays, narrative & periodontal charting D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis X-rays, narrative & periodontal charting D4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth X-rays & narrative D4910 Periodontal maintenance Once in a six month period. D4920 Unscheduled dressing change (by someone other than treating dentist) Narrative & clinical notes Prosthodontics (when medically necessary) Allowance for partial and complete dentures include adjustments within 6 months post delivery. All partial allowance includes conventional clasps, rests, and teeth. Partial and complete dentures require submission of clinical notes, narrative, and full mouth x-rays to establish medical necessity. D5110 omplete denture - maxillary X-rays & Narrative D5110 omplete denture - maxillary Full mouth x-rays, narrative, and clinical notes D5120 omplete denture - mandibular Full mouth x-rays, narrative, and clinical notes D5130 Immediate denture - maxillary Full mouth x-rays, narrative, and clinical notes D5140 Immediate denture - mandibular Full mouth x-rays, narrative, and clinical notes D5211 Maxillary partial denture - resin base Full mouth x-rays, narrative, and clinical notes D5212 Mandibular partial denture - resin base Full mouth x-rays, narrative, and clinical notes D5213 Maxillary partial denture-cast metal framework with resin denture bases Full mouth x-rays, narrative, and clinical notes D5214 Mandibular partial denture-cast metal framework with resin denture bases Full mouth x-rays, narrative, and clinical notes D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Full mouth x-rays, narrative, and clinical notes D5410 Adjust complete denture - maxillary Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 16 of 29

17 RS ode D5411 Adjust complete denture - mandibular Full mouth x-rays, narrative, and clinical notes D5421 Adjust partial denture - maxillary Full mouth x-rays, narrative, and clinical notes D5422 Adjust partial denture - mandibular Full mouth x-rays, narrative, and clinical notes D5510 Repair broken complete denture base Full mouth x-rays, narrative, and clinical notes D5520 Replace missing or broken teeth - complete denture (each tooth) Full mouth x-rays, narrative, and clinical notes D5610 Repair resin denture base - partial denture Full mouth x-rays, narrative, and clinical notes D5620 Repair cast framework - partial denture Full mouth x-rays, narrative, and clinical notes D5630 Repair or replace broken clasp - partial denture Full mouth x-rays, narrative, and clinical notes D5640 Replace broken teeth (per tooth) - partial denture Full mouth x-rays, narrative, and clinical notes D5710 Rebase complete maxillary denture Full mouth x-rays, narrative, and clinical notes D5711 Rebase complete mandibular denture Full mouth x-rays, narrative, and clinical notes D5720 Rebase maxillary partial denture Full mouth x-rays, narrative, and clinical notes D5721 Rebase mandibular partial denture Full mouth x-rays, narrative, and clinical notes D5730 Reline complete maxillary denture (chair side) Full mouth x-rays, narrative, and clinical notes D5731 Reline complete mandibular denture (chair side) Full mouth x-rays, narrative, and clinical notes D5740 Reline maxillary partial denture (chair side) Full mouth x-rays, narrative, and clinical notes D5750 Reline complete maxillary denture (lab) Full mouth x-rays, narrative, and clinical notes D5751 Reline complete mandibular denture (lab) Full mouth x-rays, narrative, and clinical notes D5760 Reline maxillary partial denture (lab) Full mouth x-rays, narrative, and clinical notes D5761 Reline mandibular partial denture (lab) Full mouth x-rays, narrative, and clinical notes D5820 Interim partial denture (maxillary) Full mouth x-rays, narrative, and clinical notes D5821 Interim partial denture (mandibular) Full mouth x-rays, narrative, and clinical notes D5850 Tissue conditioning (maxillary) Full mouth x-rays, narrative, and clinical notes D5851 Tissue conditioning (mandibular) Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 17 of 29

18 RS ode D5911 Facial moulage (sectional) Full mouth x-rays, narrative, and clinical notes D5912 Facial moulage (complete) Full mouth x-rays, narrative, and clinical notes D5913 Nasal prosthesis Full mouth x-rays, narrative, and clinical notes D5914 Auricular prosthesis Full mouth x-rays, narrative, and clinical notes D5915 Orbital prosthesis Full mouth x-rays, narrative, and clinical notes D5916 Ocular prosthesis Full mouth x-rays, narrative, and clinical notes D5919 Facial prosthesis Full mouth x-rays, narrative, and clinical notes D5922 Nasal septal prosthesis Full mouth x-rays, narrative, and clinical notes D5923 Ocular prosthesis, interim Full mouth x-rays, narrative, and clinical notes D5924 ranial prosthesis Full mouth x-rays, narrative, and clinical notes D5925 Facial augmentation implant prosthesis Full mouth x-rays, narrative, and clinical notes D5926 Nasal prosthesis, replacement Full mouth x-rays, narrative, and clinical notes D5927 Auricular prosthesis, replacement Full mouth x-rays, narrative, and clinical notes D5928 Orbital prosthesis, replacement Full mouth x-rays, narrative, and clinical notes D5959 Facial prosthesis, replacement Full mouth x-rays, narrative, and clinical notes D5931 Orbturator prosthesis, surgical Full mouth x-rays, narrative, and clinical notes D5932 Obturator prosthesis, definitive Full mouth x-rays, narrative, and clinical notes D5933 Obturator prosthesis, modification Full mouth x-rays, narrative, and clinical notes D5934 Mandibular resection of prosthesis with guided flange Full mouth x-rays, narrative, and clinical notes D5935 Mandibular resection prosthesis without guide flange Full mouth x-rays, narrative, and clinical notes D5936 Obturator prosthesis, interim Full mouth x-rays, narrative, and clinical notes D5937 Trismus appliance (not for TMD treatment) Full mouth x-rays, narrative, and clinical notes D5951 Feeding Aid Full mouth x-rays, narrative, and clinical notes D5952 Speech aid prosthesis, pediatric Full mouth x-rays, narrative, and clinical notes D5953 Speech aid prosthesis, adult Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 18 of 29

19 RS ode D5954 Palatal augmentation prosthesis Full mouth x-rays, narrative, and clinical notes D5955 Palatal lift prosthesis, definitive Full mouth x-rays, narrative, and clinical notes D5958 Palatal lift prosthesis, interim Full mouth x-rays, narrative, and clinical notes D5959 Palatal lift prosthesis, modification Full mouth x-rays, narrative, and clinical notes D5960 Speech aid prosthesis, modification Full mouth x-rays, narrative, and clinical notes D5982 Surgical stent Full mouth x-rays, narrative, and clinical notes D5984 Radiation shield Full mouth x-rays, narrative, and clinical notes D5985 Radiation cone locator Full mouth x-rays, narrative, and clinical notes D5987 ommissure splint Full mouth x-rays, narrative, and clinical notes D5988 Surgical splint Full mouth x-rays, narrative, and clinical notes D5992 Adjust maxillofacial prosthetic appliance, by report Full mouth x-rays, narrative, and clinical notes D5999 Unspecified maxillofacial prosthesis, by report Full mouth x-rays, narrative, and clinical notes D6010- D6199 All implant Services -PA Full mouth x-rays, narrative, and clinical notes D6205- D6253 Fixed partial denture pontics -PA Full mouth x-rays, narrative, and clinical notes D6545- D6634 Fixed partial denture retainers-inlays/onlays -PA Full mouth x-rays, narrative, and clinical notes D6710- D6920 Fixed partial denture retainers-crowns -PA Full mouth x-rays, narrative, and clinical notes D6930 Recement fixed partial denture -PA Full mouth x-rays, narrative, and clinical notes D6940- D6985 Other fixed partial denture services -PA Full mouth x-rays, narrative, and clinical notes D6999 Unspecified fixed prosthodontic procedure -PA Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 19 of 29

20 ode RS ORAL AND MAXILLOFAIAL SURGERY (SYMPTOMATI TEETH ONLY) Extractions of naturally exfoliating teeth are not a covered benefit Extractions will not be authorized within 6 months of Restorations and other Services at the same or an associate office Extractions peformed on an emergency basis must be retro-reviewed Extractions are covered ONLY if: 1. Tooth (teeth) is symptomatic and/or exhibits pathology 2. Extraction(s) is NOT for orthodontic purposes 3. Extraction(s) is NOT for the prophylactic extraction of 3rd molars oronal remnants - deciduous tooth - erupted tooth or D7111 exposed root elevation Periapical x-ray, clinical notes, and narrative D7140 Extraction - single tooth - erupted tooth or exposed root (elevation and/or forceps removal) Includes routine removal of tooth structure, minor smoothing of socket bone, and closure as necessary Periapical x-ray, clinical notes, and narrative D7210 Surgical removal of erupted tooth Periapical x-ray, clinical notes, and narrative D7220 Surgical removal of impacted tooth - soft tissue Periapical x-ray, clinical notes, and narrative D7230 Surgical removal of impacted tooth - partially bony Periapical x-ray, clinical notes, and narrative D7240 Surgical removal of impacted tooth - completely bony Periapical x-ray, clinical notes, and narrative D7241 Removal of impacted tooth completely bony, with unusual surgical complications, by report Periapical x-ray, clinical notes, and narrative D7250 Surgical removal of residual tooth roots (cutting procedure) Periapical x-ray, clinical notes, and narrative D7260 Oral antral fistula closure Periapical x-ray, clinical notes, and narrative D7261 Primary closure of a sinus perforation Periapical x-ray, clinical notes, and narrative D7270 Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth Periapical x-ray, clinical notes, and narrative with retrospective review claim D7285 Biopsy of oral tissue - hard (bone, teeth) -PA Periapical x-ray, clinical notes, and narrative : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 20 of 29

21 RS ode D7286 Biopsy of oral tissue - soft (all others) -PA Periapical x-ray, clinical notes, and narrative D7291 Transseptal fiberotomy / Supracrestal fiberotomy, by report Periapical x-ray, clinical notes, and narrative D7310 Alveoloplasty in conjunction with extractions - per quadrant Periapical x-ray, clinical notes, and narrative D7311 Alveoloplasty in conjunction with extractions- 1-3 teeth Periapical x-ray, clinical notes, and narrative D7320 Alveoloplasty not in conjunction with extractions - per quadrant Periapical x-ray, clinical notes, and narrative D7321 Alveoloplasty in conjunction w/o extractions- 1-3 teeth Periapical x-ray, clinical notes, and narrative D7340 Vestibuloplasty - ridge extension (secondary epithelialization) Periapical x-ray, clinical notes, and narrative D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Periapical x-ray, clinical notes, and narrative D7410 Excision of benign lesion up to 1.25 cm Periapical x-ray, clinical notes, and narrative D7411 Excision of benign lesion greater than 1.25 cm Periapical x-ray, clinical notes, and narrative D7412 Excision of benign lesion, complicated Periapical x-ray, clinical notes, and narrative D7413 Excision of malignant lesion up to 1.25 cm Periapical x-ray, clinical notes, and narrative D7414 Excision of malignant lesion greater than 1.25 cm Periapical x-ray, clinical notes, and narrative D7415 Excision of malignant lesion, complicated Periapical x-ray, clinical notes, and narrative D7440 Excision of malignant tumor-lesion diameter up to 1.25 cm Periapical x-ray, clinical notes, and narrative D7441 Excision of malignant tumor-lesion diameter greater than 1.25 cm Periapical x-ray, clinical notes, and narrative D7450 Removal of benign odontogenic cyst or tumor, lesion diameter up to 1.25 cm Periapical x-ray, clinical notes, and narrative : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 21 of 29

22 RS ode D7451 Removal of benign odontogenic cyst or tumor, lesion diameter over 1.25 cm Periapical x-ray, clinical notes, and narrative D7460 Removal of benign nonodontogenic cyst or tumor, lesion diameter of to 1.25 cm Periapical x-ray, clinical notes, and narrative D7461 Removal of benign nonodontogenic cyst or tumor, lesion diameter over 1.25 cm Periapical x-ray, clinical notes, and narrative D7471 Removal of lateral exostosis, (maxilla or mandible) Periapical x-ray, clinical notes, and narrative D7472 Removal of torus palatinus Periapical x-ray, clinical notes, and narrative D7473 Removal of torus mandibularis Periapical x-ray, clinical notes, and narrative D7485 Surgical reduction of osseous tuberosity Periapical x-ray, clinical notes, and narrative D7490 Radical resection of mandible with bone graft Periapical x-ray, clinical notes, and narrative D7510 Incision and drainage of abscess-intraoral soft tissue Periapical x-ray, clinical notes, and narrative D7511 Incision and drainage of abscess-intraoral soft tissuecomplicated Periapical x-ray, clinical notes, and narrative D7520 Incision and drainage of abscess-extraoral soft tissue Periapical x-ray, clinical notes, and narrative D7521 Incision and drainage of abscess-extraoral soft tissuecomplicated Periapical x-ray, clinical notes, and narrative D7530 Removal of foreign body from mucosa Full mouth x-rays, narrative, and clinical notes D7540 Removal of reaction producing foreign bodies Full mouth x-rays, narrative, and clinical notes D7550 Partial osteoectomy/sequestrectomy for removal of nonvital bone Full mouth x-rays, narrative, and clinical notes D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body Full mouth x-rays, narrative, and clinical notes D7610 Maxilla-open reduction(teeth immobilized) Full mouth x-rays, narrative, and clinical notes D7620 Maxilla-closed reduction(teeth immobilized) Full mouth x-rays, narrative, and clinical notes D7630 Mandible-open reduction(teeth immobilized) Full mouth x-rays, narrative, and clinical notes D7640 Mandible-closed reduction(teeth immobilized) Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 22 of 29

23 RS ode D7650 Malar and/or zygomatic arch open reduction Full mouth x-rays, narrative, and clinical notes D7660 Malar and/or zygomatic arch closed reduction Full mouth x-rays, narrative, and clinical notes D7670 Alveolus-closed reduction Full mouth x-rays, narrative, and clinical notes D7671 Alveolus-open reduction Full mouth x-rays, narrative, and clinical notes D7680 Facial bones-complicated reduction Full mouth x-rays, narrative, and clinical notes D7710 Maxilla-open reduction Full mouth x-rays, narrative, and clinical notes D7720 Maxilla-closed reduction Full mouth x-rays, narrative, and clinical notes D7730 Mandible-open reduction Full mouth x-rays, narrative, and clinical notes D7740 Mandible-closed reduction Full mouth x-rays, narrative, and clinical notes D7750 Malar and/or zygomatic arch-open reduction Full mouth x-rays, narrative, and clinical notes D7760 Malar and/or zygomatic arch-closed reduction Full mouth x-rays, narrative, and clinical notes D7770 Alveolus-open reduction stabilization of teeth Full mouth x-rays, narrative, and clinical notes D7771 Alveolus-closed reduction stabilization of teeth Full mouth x-rays, narrative, and clinical notes D7780 Facial bones-complicated eduction with fixation Full mouth x-rays, narrative, and clinical notes D7810 Open reduction of dislocation Full mouth x-rays, narrative, and clinical notes D7820 losed reduction of dislocation Full mouth x-rays, narrative, and clinical notes D7830 Manipulation under anesthesia Full mouth x-rays, narrative, and clinical notes D7840 ondylectomy Full mouth x-rays, narrative, and clinical notes D7850 Surgical discectomy, with/without implant Full mouth x-rays, narrative, and clinical notes D7852 Disc repair Full mouth x-rays, narrative, and clinical notes D7854 Synovectomy Full mouth x-rays, narrative, and clinical notes D7856 Myotomy Full mouth x-rays, narrative, and clinical notes D7858 Joint reconstruction Full mouth x-rays, narrative, and clinical notes D7860 Arthrotomy Full mouth x-rays, narrative, and clinical notes D7865 Arthroplasty Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 23 of 29

24 RS ode D7870 Arthrocentesis Full mouth x-rays, narrative, and clinical notes D7871 Non-arthroscopy lysis and lavage Full mouth x-rays, narrative, and clinical notes D7872 Arthroscopy-diagnosis, with or with out biopsy Full mouth x-rays, narrative, and clinical notes D7873 Arthroscopy-surgical: lavage and lysis of adhesions Full mouth x-rays, narrative, and clinical notes D7874 Arthroscopy-surgical: disc repositioning and stabilization Full mouth x-rays, narrative, and clinical notes D7875 Arthroscopy-surgical: synovectomy Full mouth x-rays, narrative, and clinical notes D7876 Arthroscopy-surgical: discectomy Full mouth x-rays, narrative, and clinical notes D7877 Arthroscopy-surgical debridement Full mouth x-rays, narrative, and clinical notes D7880 Occlusal orthotic device, by report Full mouth x-rays, narrative, and clinical notes D7899 Unspecified TMD therapy, by report Full mouth x-rays, narrative, and clinical notes D7910 Suture of recent small wounds up to 5cm Full mouth x-rays, narrative, and clinical notes D7911 omplicated suture- up to 5 cm Full mouth x-rays, narrative, and clinical notes D7912 omplicated suture-greater than 5 cm Full mouth x-rays, narrative, and clinical notes D7949 Lefort II or Lefort III_ with bone graft Full mouth x-rays, narrative, and clinical notes D7950 Asseous, osteoperisteal, or cartilage graft of the mandible or maxilla Full mouth x-rays, narrative, and clinical notes D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach Full mouth x-rays, narrative, and clinical notes D7952 Sinus augmentation via a vertical approach Full mouth x-rays, narrative, and clinical notes D7953 Bone replacement graft for ridge preservation-per site Full mouth x-rays, narrative, and clinical notes D7955 Repair of maxillofacial soft and/or hard tissue defect Full mouth x-rays, narrative, and clinical notes D7960 Frenulectomy-also know as frenectomy or frenotomy Full mouth x-rays, narrative, and clinical notes D7963 Frenuloplasty Full mouth x-rays, narrative, and clinical notes D7970 Excision of hyperplastic tissue-per arch Full mouth x-rays, narrative, and clinical notes D7971 Excision of pericoronal gingiva Full mouth x-rays, narrative, and clinical notes : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 24 of 29

25 RS ode D7972 Surgical reduction of fibrous tuberosity Full mouth x-rays, narrative, and clinical notes D7980 Sialolithotomy Full mouth x-rays, narrative, and clinical notes D7981 Excision of salivary gland, by report Full mouth x-rays, narrative, and clinical notes D7982 Sialodochoplasty Full mouth x-rays, narrative, and clinical notes D7983 losure of salivary fistula Full mouth x-rays, narrative, and clinical notes D7990 Emergency tracheotomy Full mouth x-rays, narrative, and clinical notes D7991 oronoidectomy Full mouth x-rays, narrative, and clinical notes D7995 Synthetic graft-mandible or facial bones, by report Full mouth x-rays, narrative, and clinical notes D7996 Implant-mandible for augmentation purposes, by report Full mouth x-rays, narrative, and clinical notes D7997 Appliance removal(not by dentist who placed appliance) Full mouth x-rays, narrative, and clinical notes D7998 Intraoral placement of a fixation device not in conjunction with a fracture Full mouth x-rays, narrative, and clinical notes D7999 Unspecified oral surgery procedure, by report Full mouth x-rays, narrative, and clinical notes Orthodontia Orthodontia for cosmetic purposes is not covered. Orthodontic coverage is only allowed when medically necessary and determined to be the primary treatment of choice or an essential part of the overall treatment plan designed by the Primary are Physician. The Member's PP needs to prescribe the braces in conjunction with the help of a dentist for the treatment of a severe condition. Full mouth x-rays, narrative, clinical notes, and letter from PP D8010 limited orthodontic treatment of the primary dentition D8020 limited orthodontic treatment of the transitional dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8030 limited orthodontic treatment of the adolescent dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8040 limited orthodontic treatment of the adult dentition Full mouth x-rays, narrative, clinical notes, and letter from PP : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 25 of 29

26 RS ode D8050 interceptive orthodontic treatment of the primary dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8060 interceptive orthodontic treatment of the transitional dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8070 comprehensive orthodontic treatment of the transitional dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8080 comprehensive orthodontic treatment of the adolescent dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8090 comprehensive orthodontic treatment of the adult dentition Full mouth x-rays, narrative, clinical notes, and letter from PP D8210 removable appliance therapy Full mouth x-rays, narrative, clinical notes, and letter from PP D8220 fixed appliance therapy Full mouth x-rays, narrative, clinical notes, and letter from PP D8660 pre-orthodontic treatment visit Full mouth x-rays, narrative, clinical notes, and letter from PP D8670 periodic orthodontic treatment visit In conjunction with active orthodontic treatment. Allowed one visit at 4-8 week intervals. D8690 orthodontic treatment(alternative billing to a contract fee) Full mouth x-rays, narrative, clinical notes, and letter from PP D8691 repair of orthodontic appliance Full mouth x-rays, narrative, clinical notes, and letter from PP. Once in a twelve month period. D8692 replacement of lost or broken retainer Once in a twelve month period. D8693 rebonding or recementing of fixed retainers Full mouth x-rays, narrative, clinical notes, and letter from PP Full mouth x-rays, narrative, clinical notes, and letter from PP D8999 unspecified orthodontic procedure, by report : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 26 of 29

27 RS ode D9110 Palliative(emergency) treatment of dental pain-minor procedure X-rays, narrative, and clinical notes. Not a covered procedure if other procedures are reported on same date of service, and same tooth is treated. D9120 fixed partial denture sectioning Full mouth x-rays, narrative, and clinical notes D9220- D9221 D9220 deep sedation/general anesthesia-first 30 minutes D9221 deep sedation/general anesthesia-each additional 15 minutes D9230 inhalation of nitrous oxide/analgesia, anxiolysis D9241 intravenous conscious sedation/analgesia-first 30 minutes D9242 ANESTHESIA SERVIES Treating Dentist must indicate on prior authorization if anesthesia services are to be performed by an in-network Anesthesiologist. Pre-authorization request for general treatment must include medical necessity documentation to warrant medical necessity of general anesthesia. Upon approval, the treating dentist will receive an authorization notification. Once treatment has been completed, the Anesthesiologist will submit for the GA performed, including a narrative and anesthesia log for retrospective review of claim. intravenous conscious sedation/analgesia-each additional 15 minutes D9248 non-intravenous conscious sedation Narrative and medical history must be included with authorization request. Anesthesia logs must be included with claim. Narrative and medical history must be included with authorization request. Anesthesia logs must be included with claim. Narrative & medical history must be included with authorization request or retrospective review claim. Narrative and medical history must be included with authorization request. Anesthesia logs must be included with claim. Narrative and medical history must be included with authorization request. Anesthesia logs must be included with claim. Narrative & medical history must be included with authorization request or retrospective review claim. : overed service N: Non-covered service -PA: overed with prior-authorization or retrospective review **RS qualifying medical diagnosis codes are listed on the last page. 27 of 29