CurrentAlaska MedicaidPolicy N/A

Dental Services — Pediatric fee schedule extract and coverage notes

This document lists CDT-coded dental services for children, with descriptions, billing notes, service authorization/written medical/tooth/surface code requirements, and maximum reimbursement amounts; it affects providers billing Alaska Medicaid for pediatric dental services.

Policy Summary

PayerAlaska Medicaid

PolicyDental Services — Pediatric fee schedule extract and coverage notes

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/1/2026 - 6/30/2026

Next Review DateN/A

Key ActionAttach written medical justification to the claim for 1–2 crowns or extractions on the same date; obtain prior authorization for 3 on the same date or 4+ within 12 months.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4/14/2026document update

$5,091.57highest explicit maximum

$711.89example high fee

$24.43example low fee

20+codes in extract

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Per-Procedure Rules

Crowns coverage with prior authorization/justification rules

Covered when the following documentation or prior authorization rules are met:

Crowns billed to Alaska Medicaid must include written medical justification on the claim when 1–2 crowns are provided on the same date of service; written justification is not required if prior authorization is submitted on the claim.

Prior authorization required if

3 crowns on the same date of service
4 or more crowns within a 12‑month period

These rules apply to multiple crown CDT codes (examples shown in the schedule include D2390, D2712, D2720, D2722, D2740, D2751, D2752, D2791, D2794, D2928 and similar crown codes) and are noted in the line item billing notes.

Endodontic coverage and prior authorization

Endodontic therapy coverage is conditional for retreatment procedures:

Standard endodontic therapy codes (e.g., D3310, D3330) are covered with the listed maximum fees; tooth code reporting is required where indicated.

Retreatment of previous root canal therapy (examples: D3346, D3347, D3348) requires Service Authorization (marked 'X') and therefore prior authorization before payment consideration.

Providers must submit tooth-level identification for endodontic items marked 'Tooth Code Required' as indicated on the line item.

Pediatric dental coverage items (excerpt)

Excerpted pediatric dental items show coverage status, tooth‑level reporting, and case‑by‑case review requirements:

D3330 (endodontic therapy, molar) is covered; tooth code reporting is required (Tooth Code Required = X). Maximum = $711.89.

Certain retreatment endodontic codes (D3346, D3348) are covered but require Service Authorization (X) and tooth code reporting; maximums shown (e.g., D3346 $570.44; D3348 $766.04).

Complete denture codes (D5110, D5120) are covered but many denture and denture adjustment/repair codes require Service Authorization with medical justification (marked 'X').

Pediatric dental code coverage entries (examples)

Representative per‑procedure coverage entries with billing notes and authorization indicators:

Prosthesis and obturator items (e.g., D5931) are covered with maximums shown (D5931 Maximum = $977.28); some prosthetic codes list 'Written Medical Justification Required = X' and 'Maximum = By Report' indicating case‑by‑case review.

Pontic and crown-related codes (e.g., D6205, D6710, D6720 series) may carry Service Authorization indicators or billing notes; example D6205 shown with maximum $692.24.

Selected crown codes (example D6710, D2740, D2720, D2928) include the crown multiple‑count billing note: attach written medical justification for 1–2 crowns on the same date; 3 crowns on date of service or 4+ within 12 months must be prior authorized for consideration.

Partial coverage criteria and administrative notes

Partial coverage and administrative notes for selected CDT entries:

Facial bone and oral surgery codes list maximum allowable amounts where applicable (examples: D7680, D7730, D7770, D7780 with maximums shown in the schedule).

Anesthesia/sedation and other high‑complexity items may require prior authorization and submission of chart notes for consideration (see anesthesia/sedation entries).

Some prosthetic and specialty therapy codes (for example items with 'Maximum = By Report' or 'Written Medical Justification Required = X') will be reviewed case‑by‑case and require submission of written medical justification.

Coverage criteria for select procedures

Coverage considerations for multiple or high‑cost procedures and reporting requirements:

Crowns: attach written medical justification to claim for 1–2 crowns on the same date; 3 crowns on the same date of service or 4 or more crowns within 12 months must be prior authorized for consideration. Written justification is not required if prior authorization is submitted on the claim.

Extractions: attach written medical justification to claim for 1–2 extractions on the same date; 3 extractions on the same date of service or 4 or more extractions within 12 months must be prior authorized for consideration. Written justification is not required if prior authorization is submitted on the claim.

Many restorative and operative codes require tooth and/or surface reporting where indicated (Tooth Code Required = X; Surface Code Required = X); providers must report tooth/surface information as shown per line item.

Adult dental coverage criteria

Adult dental coverage entries and their authorization/documentation rules:

Denture and partial denture services (examples: D5110, D5120, D5213, D5214 and related adjustment/repair codes) require Service Authorization with medical justification (marked 'X') as indicated on the line items.

Extractions and impacted tooth removal (e.g., D7140, D7210, D7220, D7230) carry the extraction multiple‑count billing note: attach written medical justification for 1–2 extractions on the same date; 3 on the same date or 4+ within 12 months must be prior authorized for consideration. For select extraction codes (e.g., D7210) Service Authorization may be indicated (X).

Case‑by‑case / By Report examples

Some prosthesis and specialty therapy codes (e.g., D5922, D5923, D5953, D7899) require written medical justification or list 'Maximum Allowable = By Report', indicating reimbursement and approval will be determined on a case‑by‑case basis.
High‑cost surgical and facial bones procedures have specified maximum allowable amounts listed (examples in schedule).

Per-code coverage entries

Per‑code coverage rules and requirements (selected line items):

D7770 — Covered; Maximum Allowable $1,064.24 as listed in the schedule.

D7780 — Covered; Maximum Allowable $2,556.32 as listed in the schedule.

D7951 and D7998 — Service Authorization Required (X); maximums noted as 'By Report' for some grafting/fixation/sinus augmentation codes, implying case‑by‑case review and prior authorization.

D9222/D9223 — General anesthesia entries: must be prior authorized for consideration and providers must submit chart notes from the completed procedure with the claim; D9222 maximum $170.76.

D9230/D9244/D9245 — Inhalation and minimal/moderate sedation entries: attach written medical justification where indicated; maximums shown (example D9230 $57.01; D9244 $188.33).

Procedure Codes and Fee Table Excerpts

Example evaluation codes and feesCPT | HCPCS | mixedCovered

D0120	PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT; Maximum $48.86
D0140	LIMITED ORAL EVALUATION - PROBLEM FOCUSED; Maximum $65.15
D0145	ORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE; Maximum not listed in extract

Restorative codesCPT | HCPCS | mixedCovered

D2140	AMALGAM-ONE SURFACE; Maximum $106.89
D2330	RESIN-ONE SURFACE, ANTERIOR; Maximum $127.56
D2390	RESIN-BASED COMPOSITE CROWN, ANTERIOR; Maximum $247.98

Endodontic codesCPT | HCPCS | mixedCovered

D3310	ENDODONTIC THERAPY, ANTERIOR; Maximum $521.62
D3330	ENDODONTIC THERAPY, MOLAR; Maximum $711.89

Selected pediatric dental procedure codes and feesCPT | mixed

D3330	ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) - Maximum $711.89; Tooth Code Required
D3346	RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - Service Authorization Required; Maximum $570.44; Tooth Code Required
D3348	RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLAR - Service Authorization Required; Maximum $766.04; Tooth Code Required
D5110	COMPLETE DENTURE - MAXILLARY - Maximum $1,119.80
D5120	COMPLETE DENTURE - MANDIBULAR - Maximum $1,145.25

Selected prosthesis/pontic and related pediatric dental codesCPT | HCPCS | mixedCovered

D5923	OCULAR PROSTHESIS, INTERIM
D5931	OBTURATOR PROSTHESIS, SURGICAL
D5932	OBTURATOR PROSTHESIS, DEFINITIVE
D5933	OBTURATOR PROSTHESIS, MODIFICATION
D5934	MANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGE
D5951	FEEDING AID
D5982	SURGICAL STENT
D6205	PONTIC - INDIRECT RESIN BASED COMPOSITE

Selected crown codes with billing notesCPT | mixedCovered

D6710	CROWN - INDIRECT RESIN BASED COMPOSITE
D6740	CROWN - PORCELAIN/CERAMIC
D6751	CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL
D6791	CROWN-FULL CAST PREDOMINANTLY BASE METAL

Selected extraction and impacted tooth codesCPT | mixedCovered

D7111	EXTRACTION, CORONAL REMNANTS - DECIDUOUS TOOTH
D7140	EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT
D7210	EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING
D7220	REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

Adult preventive/operative examplesCPTCovered

D0120	Periodic oral evaluation - established patient
D0150	Comprehensive oral evaluation - new or established patient
D2140	Amalgam - one surface, primary or permanent
D2161	Amalgam - four or more surfaces, primary or permanent
D2330	Resin - one surface, anterior

Orthodontic services (children)CPTCovered

D8010	Limited orthodontic treatment of the primary dentition
D8080	Comprehensive orthodontic treatment of the adolescent dentition

PreventiveCPTCovered

D1110	PROPHYLAXIS-ADULT
D1206	TOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR MODERATE TO HIGH CARIES RISK PATIENTS

RestorativeCPTCovered

D2140	AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT
D2330	RESIN-ONE SURFACE, ANTERIOR
D2391	RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR

EndodonticsCPTCovered

D3310	ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION)
D3330	ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION)

Denture and partial denture servicesCPTCovered

D5110	Complete denture - maxillary
D5120	Complete denture - mandibular
D5213	Maxillary partial denture - cast metal framework with resin base
D5214	Mandibular partial denture - cast metal framework with resin base

Extractions and impacted tooth removalCPTCovered

D7140	Extraction, erupted tooth or exposed root
D7210	Extraction requiring removal of bone and/or sectioning
D7220	Removal of impacted tooth - soft tissue
D7230	Removal of impacted tooth - partially bony

Facial bones reduction proceduresCPTCovered

D7680	Facial bones - complicated reduction with fixation
D7780	Facial bones - complicated reduction with fixation and multiple approaches

Selected procedure codes listedCPTCovered

D7770	Tooth extraction, impacted (list shows MAX $1,064.24)
D7780	Facial bones — complicated reduction with fixation (MAX $2,556.32)
D9222	General anesthesia - first 15 minutes (MAX $170.76)
D9230	Inhalation of nitrous oxide/analgesia (MAX $57.01)
D9244	In-office minimal sedation - enteral (MAX $188.33)
D9999	Unspecified adjunctive procedure, by report

inv-25: Crown count prior authorization threshold

Threshold4 or more crowns in 12 months require prior authorization; 3 crowns on a single date may require written medical justification

Partial threshold guidanceAttach written medical justification to claim if 1-2 crowns on date of service (unless prior authorization submitted)

ScopeApplies to crown codes listed with billing notes (e.g., D2390, D2712, D2720, D6710)

Provider Documentation, Authorization, and Billing Actions

Prior Authorization

Crown prior authorization / written justification requirements

Attach written medical justification to the claim when billing 1–2 crowns on the same date of service; 3 crowns on the same date of service, or 4 or more crowns in a 12‑month period must be prior authorized for consideration. Written medical justification is not required if prior authorization is submitted on the claim.

Applies to listed crown codes (e.g., D2390, D6710, D6740, D6751).

Prior Authorization

Specific service authorization requirement (D2975)

D2975 (Coping) is marked Service Authorization = X and requires prior authorization before services are provided or billed.

Submit prior authorization per Alaska Medicaid procedures when billing D2975.

Prior Authorization

Definitions and Policy Notes

inv-53: CDT codes copyright

Document updateUpdated 4/14/2026

RBRVS rounding mentionCoverage and rates are subject to change (context note).

inv-54: RBRVS rounding

Rounding ruleRBRVS-based rates are rounded to the nearest cent following adjustments for multiple units and cutbacks

Effect on reimbursementReimbursement may vary slightly from published rates due to rounding

Applies to

Policy Summary

PayerAlaska Medicaid

PolicyDental Services — Pediatric fee schedule extract and coverage notes

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/1/2026 - 6/30/2026

Next Review DateN/A

Key ActionAttach written medical justification to the claim for 1–2 crowns or extractions on the same date; obtain prior authorization for 3 on the same date or 4+ within 12 months.

SourceLink

On This Page

D9999 — Unspecified adjunctive procedure; reimbursement determined 'By Report' per line item and requires supporting documentation for payment consideration.

inv-26: Maximum fee per code

General ruleMaximum fee varies by CDT code; some codes list explicit dollar maximums while others are 'By Report' for case‑by‑case payment determination

Examples of explicit maximumsD3330 $711.89; D7770 $1,064.24; D7780 $2,556.32

'By Report' noteHigh‑complexity/prosthetic codes may be reimbursed 'By Report' requiring documentation for determination

inv-27: Crowns prior auth threshold

Same‑date threshold3 crowns on the same date of service require prior authorization (billing notes indicate attach written justification for 1-2; 3 on date or 4+ in 12 months must be prior authorized)

Example codes referencedD6710, D6740, D6751, D6791 (crowns with billing notes)

ExceptionWritten medical justification not required if prior authorization submitted on claim

inv-28: Extractions prior auth threshold

Same‑date threshold3 extractions on the same date of service require prior authorization (attach written medical justification if 1-2; 3 on date or 4+ in 12 months must be prior authorized)

Example extraction codesD7140, D7210, D7220, D7230 (billing notes reference thresholds)

Written justificationWritten medical justification not required if prior authorization submitted on claim

inv-29: Maximum for D8010

D8010 maximum$1,500.00

Authorization flagD8010 has Service Authorization Required = X (must be prior authorized)

Provider requirementService may only be performed by an orthodontist (billing note)

inv-30: Maximum for high-cost grafts (by report noted)

Listed maximum$5,091.57 (osseous/osteoperiosteal or cartilage graft of mandible or maxilla — by report entry shows this maximum)

'By Report' entriesCertain grafting and sinus augmentation codes show 'By Report' indicating case‑by‑case review (e.g., D7951 maximum By Report)

DocumentationReimbursement for high-cost grafts requires submitted documentation for review

inv-31: Crowns prior authorization threshold

Same‑date threshold3 crowns on date of service require prior authorization; 4 or more crowns in 12 months require prior authorization

Claim documentationAttach written medical justification for 1-2 crowns on date of service unless prior authorization is submitted on claim

Applies to adult crown codesE.g., D2740, D2751, D2791, D2794 — billing notes mirror pediatric crown rules

inv-32: Extractions prior authorization threshold

Same‑date threshold3 extractions on date of service require prior authorization; 4 or more in 12 months require prior authorization

Claim documentationAttach written medical justification for 1-2 extractions on date of service unless prior authorization is submitted on claim

Applies across adult extraction codesE.g., D7240, D7241, D7250 billing notes reference the same thresholds

inv-33: Extraction prior authorization threshold

Extraction prior‑auth rule3 extractions on a single date of service, or 4 or more extractions within 12 months, must be prior authorized for consideration

Written justification optionFor 1-2 extractions on a date of service, attach written medical justification to claim; not required if prior authorization submitted

Referenced codesD7140, D7210, D7220 (billing notes in multiple adult entries)

inv-34: Maximum Allowable Payment Examples

High‑value examplesD7780 Maximum $2,556.32; D7770 Maximum $1,064.24; D9222 Maximum $170.76

ContextExamples illustrate range of explicit maximum allowable payments in schedule (not exhaustive)

'By Report' contrastSome codes remain 'By Report' and require documentation for reimbursement determination

Endodontic retreatment prior authorization

Retreatment of previous root canal therapy codes (D3346, D3347, D3348) are marked Service Authorization = X and require prior authorization for consideration.

Tooth code is required for these retreatment codes.

Documentation Required

Authorization and documentation requirements (excerpt)

Some procedure entries require Service Authorization (indicated by 'X') and/or Written Medical Justification; many endodontic and restorative items also require reporting of the tooth code.

Service Authorization = 'X' denotes prior authorization is required.
Tooth Code Required must be reported where indicated.

Billing Rule

Prior authorization and billing notes for prosthetic/pontic and crown codes

Certain prosthetic and pontic codes show Service Authorization = X or note 'See Billing Note', indicating prior authorization or special billing instructions; crown codes have specific prior authorization/billing note rules as detailed in crown billing notes.

Examples: D6205 (Service Authorization = X); other pontic/prosthesis codes may require written medical justification or special billing handling.

Billing Rule

Crown prior authorization/billing note

For crowns (e.g., D6710, D6740, D6751), attach written medical justification for 1–2 crowns on the date of service; 3 crowns on the date of service or 4 or more in 12 months must be prior authorized. Written justification is not required if prior authorization is submitted on the claim.

D6710/D6740/D6751 include 'See Billing Note' and tooth code required indicators.

Prior Authorization

Extraction prior authorization/billing note

For extractions (e.g., D7220, D7230, D7140), attach written medical justification when billing 1–2 extractions on the same date of service; 3 extractions on the same date of service or 4 or more within 12 months must be prior authorized for consideration. Written medical justification is not required if prior authorization is submitted on the claim.

D7210 is marked Service Authorization = X and requires prior authorization where indicated.

Documentation Required

Prior authorization / documentation requirements (partial)

Certain anesthesia and sedation codes must be prior authorized for consideration; chart notes from the completed procedure must be submitted with the claim.

Examples: D9211, D9223, D9239, D9243, D9222 require prior authorization and chart notes as specified.

Billing Rule

Special billing referral (Frenectomy)

Frenectomy codes (e.g., D7962) have special billing requirements and direct providers to follow the Alaska Medicaid Frenectomy Policy.

Refer to Alaska Medicaid Frenectomy Policy for billing instructions when submitting claims for D7962.

Note

Crown prior authorization and written justification guidance

Attach written medical justification to the claim when billing 1–2 crowns on the same date of service; 3 crowns on the same date of service, or 4 or more crowns in a 12‑month period must be prior authorized for consideration. Submission of prior authorization on the claim waives the need to attach written justification.

This guidance applies across adult and pediatric crown entries where billing notes indicate 'See Billing Note'.

Prior Authorization

Extraction prior authorization and written justification guidance

Attach written medical justification to the claim when billing 1–2 extractions on the same date of service; 3 extractions on the same date of service, or 4 or more extractions in a 12‑month period must be prior authorized for consideration. Written justification is not required if prior authorization is submitted on the claim.

Applies to extraction codes with billing notes (e.g., D7140, D7220, D7230, D7240).

Documentation Required

Specific service authorization flag (D7250)

D7250 (Removal of residual tooth roots) is designated Service Authorization Required = X and requires prior authorization as indicated.

Tooth code reporting is required for D7250.

Prior Authorization

Prior authorization for denture-related services

Many denture and denture adjustment/repair codes in the D5110–D5761 range require Service Authorization with Medical Justification (marked 'X') prior to reimbursement consideration.

Examples: D5110 and D5120 require Service Authorization with Medical Justification = X.

Documentation Required

Extraction prior authorization and documentation rules

For multiple extractions on a single date or multiple extractions within 12 months, attach written medical justification or obtain prior authorization as specified in extraction billing notes (e.g., D7140, D7220, D7230).

Written justification not required if prior authorization is submitted on the claim.

Documentation Required

Case-by-case authorization/documentation

Certain prosthesis and specialty therapy codes (for example D5922, D5923, D5953, D7899) are marked 'Written Medical Justification = X' or list Maximum Allowable = By Report, indicating these items are reviewed case‑by‑case and require supporting documentation.

Submit written medical justification and supporting documentation when billing codes with 'By Report' maximums or where written justification is required.

Prior Authorization

Anesthesia/Sedation prior authorization note

Anesthesia and intravenous sedation codes (e.g., D9222, D9223, D9239, D9243) must be prior authorized for consideration; submit chart notes from the completed procedure with the claim.

D9222/D9223 and D9239/D9243 include billing notes stating prior authorization and chart notes are required.

Prior Authorization

Service authorization indicated (grafting/fixation/sinus augmentation)

Service Authorization Required = X is indicated for select grafting, fixation and sinus augmentation codes (e.g., D7951, D7995, D7998), and these require prior authorization per billing notes.

D7951 and D7998 are examples where Service Authorization = X and reimbursement may be 'By Report'.

Documentation Required

Written medical justification requirement (sedation/nitrous oxide)

Attach written medical justification to the claim for nitrous oxide, minimal or moderate sedation services where marked (e.g., D9230, D9244, D9245).

D9230 (nitrous oxide) and D9244/D9245 (minimal/moderate sedation) list 'Attach written medical justification to claim' where Written Medical Justification = X.

All RBRVS‑based fee schedule entries in this document

inv-55: Service Authorization Required

DefinitionService Authorization Required = 'X' denotes that prior authorization/service authorization is required for that code

ExamplesD3346, D8010, D7210, D7951, D9222 are entries showing Service Authorization Required = X or 'See Billing Note'

Action for providersSubmit prior authorization or follow billing note instructions when 'X' or 'See Billing Note' is present

inv-56: Tooth Code Required

RequirementTooth Code Required indicates the specific tooth identifier must be reported with the claim

ExamplesD3330, D3346, D6710 and many restorative/extraction codes list Tooth Code Required = X

Claim impactClaims missing required tooth codes may be noncompliant with billing notes

inv-57: Prior authorization threshold for crowns/extractions

Rule summaryPrior authorization requirement for crowns/extractions is tied to counts: attach written justification for 1-2 on a date of service; 3 on a date of service or 4+ in 12 months must be prior authorized for consideration

Applies to codesReferenced in billing notes for crown codes (e.g., D2390, D2720, D6710) and extraction codes (e.g., D7140, D7220, D7230)

Written justificationWritten medical justification may substitute for prior authorization on claim submission when allowed

inv-58: Frenectomy billing

Billing noteFrenectomy codes (D7955, D7962) reference special billing requirements and direct to Alaska Medicaid Frenectomy Policy

ExamplesD7955 Maximum $342.56; D7962 Maximum $303.98

Provider actionFollow referenced Alaska Medicaid Frenectomy Policy for billing instructions

inv-59: Prior authorization for anesthesia/sedation

Authorization requirementCertain anesthesia and sedation codes must be prior authorized for consideration and require submission of chart notes with the claim

ExamplesD9222/D9223/D9239/D9243 (general anesthesia/IV sedation) and D9244/D9245 (minimal/moderate sedation) note prior authorization or written medical justification requirements

DocumentationSubmit chart notes from completed procedure when prior authorization is required

inv-60: Maximum Allowable

Maximum Allowable conceptMaximum Allowable is the listed per‑code reimbursement ceiling; some codes list specific dollar amounts while others are 'By Report'

ExamplesD7780 $2,556.32; D7770 $1,064.24; several entries list 'By Report' (case‑by‑case)

UseProviders should reference the per‑code Maximum Allowable when billing; 'By Report' entries require supporting documentation

inv-61: Written Medical Justification / Prior Authorization

When written justification is acceptableAttach written medical justification to claim for 1-2 crowns or 1-2 extractions on a single date of service; for 3 on a date or 4+ in 12 months obtain prior authorization for consideration

Codes requiring bothSome codes are marked Service Authorization Required = X and also indicate Written Medical Justification = X (see schedule lines for specifics)

Submission noteWritten medical justification is not required if prior authorization was submitted on the claim

inv-62: Service Authorization Required with Medical Justification

Service Authorization flagService Authorization Required = 'X' or 'See Billing Note' indicates prior authorization is required; follow the billing note instructions for submission

Example codesD7250 (Service Authorization = X); D7210 and other operative codes may show 'X' or 'See Billing Note'

Provider actionObtain prior authorization when indicated and include required documentation with the claim

inv-63: By Report

'By Report' meaning'By Report' indicates reimbursement will be determined based on submitted documentation and review (case‑by‑case)

ExamplesD2542, D5932, D7951, D5922, D5923, D5953, D7899 show By Report or list 'By Report' as maximum

Provider actionSubmit detailed supporting documentation when billing 'By Report' codes to support reimbursement determination

inv-64: Written Medical Justification

RequirementWritten medical justification = X indicates the provider must attach written medical justification to the claim

ExamplesD5922, D5923, D5953, D9230, D9244/D9245 list Written Medical Justification = X

When usedUsed for case‑by‑case services or sedation/anesthesia where justification is required instead of or in addition to prior authorization

inv-65: Service Authorization Required

Service Authorization indicatorService Authorization Required indicated by 'X' or 'See Billing Note' for select codes; obtain prior authorization as directed

Common applicationsRetreatment endodontic codes (D3346/D3348), orthodontic/service codes (D8010 etc.), and various surgical/anesthetic codes use this indicator

Provider instructionFollow billing notes: submit prior authorization and required documentation (chart notes, written justification) when indicated